Skip to main content

Full text of "The Causes and the Prevention of Blindness"

See other formats 


Google 



This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 

to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 

to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 

are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 

publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing tliis resource, we liave taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 
We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain fivm automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attributionTht GoogXt "watermark" you see on each file is essential for in forming people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liabili^ can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 

at |http: //books .google .com/I 



THE CAUSES 



AND THE 



PREVENTION OF BLINDNESS 



THE CAUSES 



AND THE 



PREVENTION OF BLINDNESS 



'\ 



THE 

CAUSES 



AND THE 



PREVENTION 



OF 



BLINDNESS 



BY 



DR. ERNST FUCHS, 

Professor of Ophthalmology in the University of Liege, 



VIRIBUS UNITIS. 



The Essay which gained the Prize of £80 offered by the Society for 

the Prevention of Blindness in London. 



TRANSLATED BY 

DR. R. E. DUDGEON, 
Author of ^^The Human Eye: its Optical Construction,''^ 

WITH A FEW NOTES BY 

DR. M. ROTH. 



BAILLIERE, TINDALL & COX, 20, KING WILLIAM ST., STRAND, W.C. 

1885. 



/6U2U . €. 2. . (^ 



r\N L/^: 




LONDON : 

I'RINTED DY 

JOHN BALE AND SONS, GREAT TITCIIFIELD STREET, 

OXFORD STREET, \V. 



REPORT OF THE HONORARY SECRETARY 

OF 

The Society for the Prevention of Blindness, and the 
Improvement of the Physique of the Blind. 

48, WiMPOi.E Street, 

London, W. 

June^ 1883, 

As the Hon. Secretary {pro, tem^ of this Society, I consider it my duty 
to mention that during the five years and a-half of its existence over 100,000 
papers, viz., leaflets, prospectus, reports and pamphlets have been gra- 
tuitously distributed, and that this Prize Essay (which is the property of the 
Society) " On the Causes and the Prevention of Blindness," by Dr. Fuchs, 
Professor at Liege in Belgium, was published this year by J. F. Bergmann, 
in Wiesbaden in German, the language in which the MS. was written. The 
German edition consists of 1,000 copies, and is sold at a nominal price to 
cover the publisher's expenses. A French translation, by Dr. Fieuzal, is in 
the press. An Italian translation will be published as soon as the funds of 
the Society will permit. At the third International Congress of Hygiene at 
Turin, in 1880, I called the attention of the Congress to the subject of the 
prevention of blindness, and it was resolved that it should again be brought 
forward at the fourth Congress in Geneva, in 1882. Meanwhile the Society 
offered a price of ;^8o for the best essay on the Causes and Prevention of 
Blindness, written in English, French, German, or Italian, It is due to the 
generosity of a gentleman (whom I am not permitted to name) appreciating 
the importance of the aim the Society is pursuing that the prize could be 
offered, as he contributed five-eighths of the money. The Society has also 



VI. HON. secretary's report. 

to thank the same gentleman for his aid in the publication of the English 
translation by a contribution of almost half of its expense. The programme 
of the essay, and the report of the secretary of the International jury, which 
was read at the fifth Congress at the Hague, in August, 1884, are here 
reprinted. 

As the Society wishes that this book may be read and understood by the 
general reader, I have added a diagram of the eye and a glossary of all tech- 
nical terms, as well as a list of the Society's publications which are dis- 
tributed amongst the various classes of the population. 

The Society's thanks are due to Dr. Dudgeon, who has for a long time 
paid much attention to eye-diseases, for kindly undertaking the transla- 
tion of this essay and its careful revision for the press. 

The Society hopes that their exertions on behalf of the Prevention of 
Blindness will contribute to the diminution of the still largely prevailing 
ignorance of the public who arc not generally aware that two thirds of the 
30,000 blind in England, and of the 320,000 in Europe, owe their misfortune 
merely to ignorance and neglect. It is desirable that more attention should 
be paid to the diminution of the immense amount of misery represented by 
these numbers as well as to the great expense to the country the existence 
of so many blind persons entails, an expense which is not represented by 
the mere cost of maintenance, but also by the loss of the productive labour 
of these blind persons. 

Dr. roth. 
Hon, Secretary and Treasurer^ pro tern. 



Programme. 



Offer of a Prize on the Prevention of Blindness. 

The Fifth International Congress for Hygiene which meets in 1884 in 
the Hague (Holland) will award the prize of ^80 offered by the London 
Society for the Prevention of Blindness to the author of the best unpublished 
essay in English, French, Italian or German, On the Causes of Blindness 
and the best Practical Means for Preventing it. In addition to the chief 
prize the International Society for the amelioration of the lot of the blind, 
proposes to award a second prize of £6p (or two prizes of £26)^ as also a 
medal and diploma, to the author of any essay or essays considered as 
specially meritorious by the prize jury. These latter prizes will be given on 
the occasion of the celebration in Paris of the centenary anniversary of the 
foundation of the first asylum for the blind by Hauy. 

The Fourth International Congress for Hygiene which m6t in Geneva 
in September, 1882, accepted, on the proposal of the prize givers, the 
following programme for the prize award : — 

1. Causes of Blindness, — a. Influence of heredity, diseases of parents, 
consanguineous marriages, &c. b. Eye diseases of infancy, vari- 
ous inflammations. c. School period, progressive myopia, &c. 

d. General diseases, diatheses, various fevers, poisoning, &c. 

e. Influence of occupations, accidents and injuries, sympathetic oph- 
thalmia, f Social and climatic influences; infectious eye diseases; 
unwholesome, over-crowded, ill-lighted dwelling places, &c. g. De- 
fective or total absence of treatment of eye affections. 

2. The most appropriate preventive measures are to be stated for 

each of these groups, a. Legislative measures, b. Hygienic and 
professional measures, c, Paedagogic measures, d. Medical and 
philanthropic measures. 

The Geneva Congress chose an international prize jury consisting of 
the following gentlemen : — 



• •• 



Vlll. PROGRAMME. 



Germany — Dr. H. COHN, Professor of Ophthalmology in Breslau. Sani- 
tary Councillor Dr. Varrentrapp, of Frankfort-on-the-Maine. 

England— T^x, M. Roth, Honorary Secretary and Treasurer of the 
Society for the Prevention of Blindness. Dr. Streatfield, Pro- 
fessor of Ophthalmology in London. 

France — Dr. Fieuzal, Physician to the Blind Asylum of the Quinze- 
Vingts in Paris. Dr. Layet, Professor of Hygiene in Bordeaux. 

Italy — Dr. Reymond, Professor of Ophthalmology in Turin. Dr. 
SORMANi, Professor of Hygiene in Pavia. 

Holland— 'Dx. Snellen, Professor of Ophthalmology in Utrecht. 

Switzerland— "Dx, APPIA, of Geneva. Dr. DUFOUR, Physician to the 
Eye Hospital in Lausanne. Dr. Haltenhoff, extra-academical 
Teacher of Ophthalmology in Geneva (Secretary of the Prize Jury). 

As Drs. Varrentrapp and Appia resigned, the prize jury was completed 
by the nomination of Dr. Berlin, Professor of Ophthalmology in Stuttgart, 
and Dr. Coursserant, Oculist in Paris. 

The Society for the Prevention of Blindness, and the International 
Society for the Amelioration of the Lot of the Blind, retain the copyright 
of the essays to which prizes shall be awarded, and the right to publish and 
distribute them as shall seem fit to them, either completely or in abstract, 
in various languages. 

Manuscripts must be sent to the Secretary before the 31st March, 1884. 

Each essay must bear a motto corresponding with one in a sealed 
envelope, containing the christian and surnames, title and address 
of the author. The envelopes will not be opened until the award of the 
prize jury is given. 

Dr. G. Haltenhoflf, 

Geneva^ November, 1882. Secretary. 



Report of the Jury. 

(Annales d'oculistique, tome XCIL, p. 142.) 
Messieurs, 

.... J'ai, Messieurs, la satisfaction de pouvoir vous annoncer, que 
le concours que vous avez pris sous votre patronage a pleinement r^ussi. 
Le jury a regu sept travaux, la plupart considerables, h. savoir : 

Quatre en allemand. Deux en anglais, Un en frangais. 

Apr^s avoir circuit pendant plusieurs mois entre les mains des membres 
du Jury, habitant les divers pays, ces sept mdmoires ont 6t6 remis k votre 
secretaire g6n6ra\ et ddposds dans une des salles du Binnenhof, ou les 
membres du Jury, venus au Congr^s, ont pu de nouveau les examiner k loisir 
et dchanger leurs iddes et leurs impressions sur la valeur comparative des 
travaux concurrents. 

Vous les voyez ici rdunis sur la table de la prdsidence, ou ils sont encore 
en ce moment k votre disposition. 

Plusieurs des membres du Jury n'ont pu se rendre k la Haye ; la plupart 
d^entre eux ont envoyd leur appreciation par dcrit. Le jury a dte k peu pr^s 
unanime pour conferer le prix de 2000 francs de la " Societe pour la preven- 
tion de la cecite " au memoire allemand portant la devise : Viribus unitis. 

Le mdmoire, de 545 pages manuscrites, en 2 volumes, ayant pour titre : 
" Die Ursachen und die Verhiitung der Blindheit " est une oeuvre originale 
de grand merite, r^pondant, mi eux et plus compl^tement que les autre 
travaux concurrents, aux diverses questions du programme. Joignant k 
I'experience personelle du clinicien la connaissance complete de la litt^rature 
speciale du sujet, I'auteur en a embrasse toutes les faces, avec une compe- 
tence, une exactitude, une largeur et une supdrioritd de vues, qui ont frappc 
tous les membres du Jury. Ayant toujours present k I'esprit le but pratique 
et philanthropique du concours, et prenant comme point de depart une 
definition de la cecite basee sur I'etat de dependance sociale et economique 
de Faveugle, Pauteur a su 6tre complet et scientifique, tout en dvitant des 
details statistiques superflus, et des considerations de pathologie et de 
th^rapeutique plus ou moins en dehors du sujet. Son travail presente un 
ensemble bien coordonne, dont chaque chapitre peut aussi etre consultd 
isolement avec fruit. Partout la place la plus large est donnee k I'etude des 
mesures prophylactiques propres a diminuer le nombre des aveugles In- 
curables. Aussi le jury croit-il devoir exprimer le desir, que ce remarquable 
memoire soit bientot public et, si possible, traduit en d'autres langues, soit 
par les soins de la " Societe anglaise pour la prevention de la cecite," soit de 

toute autre mani^re. 

Pour le Jury, 

Dr. G. HaltenhoJBT. 



PUBLICATIONS 



OF THE 




ocictg for ihi> f reui^nlioii 4 Slindness. 



1. Advice to Mothers who do not wish their Children 

to be Blind. 

2. Instructions to Midwives and Monthly Nurses con- 

cerning the special care to be bestowed on Newly- 
born Children, in cases of Eye Inflammation. 
(Published by the Saxon Minister of the Interior, i6th January, 
1882). 

3. Ocular Hygiene ; or Instructions for Preserving a 

Good Eyesight. 

4. Hints for the Prevention of the most common 

Accidents causing Blindness, and Instruction how 
to act till Medical aid can be obtained. 

5. Prevention of Blindness, By Dr. Roth (re-printed from the 

Transactions of the Conference on the Blind, held at York in 
1883.) 

6- The Physical Education of the Blind, by Dr. Roth, 

(re-printed from the Transactions of the Conference on the 
Blind, held at York in 1883.) 

7- Prospectus of the Society for the Prevention of 

Blindness. 

8. Five Yearly Reports from 1880 to 1884. 



PREFACE. 



AT the fourth International Congress for Hygiene, 
which met in September, 1882, at Geneva, the 
London Society for the Prevention of Blindness offered, 
through its Hon. Secretary, Dr. M. Roth, a prize for the 
best Essay on the Causes and Prevention of Blindness. 
At page vii. will be found the terms of the prize com- 
petition, and at page ix. the award of the Jury by which 
the prize was adjudged to the present work. 

By giving the prize the essay became the property of 
the Society. Entrusted by the Society with the publi- 
cation pf the essay in German, I sent the manuscript to 
press with a few unimportant alterations. 

The extent and arrangement of the matter were laid 
down for me in the programme. Acting in conformity 
with the intention shown in the terms of the prize giver's 
offer, I have dwelt chiefly on the prophylaxis of blind- 
ness and therefore have gone into the causes of blind- 
ness only as far as a knowledge of them is indispensable 
for the framing a rational prophylaxis. As regards causes 



Xll. PREFACE. 



of blindness which are unpreventable I have merely made 
cursory mention of them. I have refrained from giving 
full statistics relating to blindness as these would not 
rightly come within the limits of the terms of the prize 
offer. 

The methods of medical treatment form an important 
part of the prophylaxis of blindness. If they are not 
found in this essay the reason is that the subject is 
treated in full detail in every manual of ophthalmology. 

The chief aim of this essay is to rouse the interest of 
ever increasing circles in the war against blindness. I 
shall esteem myself fortunate if I shall be able by 
means of it to do something towards diminishing this 
frightful calamity. 

Dr. ERNST FUCHS. 

Liege, November^ 1884. 



CONTENTS. 



PAGE 

Report of Hon. Secretary of Society for Prevention of Blindness v. 

JL X C iiX^C ••• ••• ••• ••• ••• ••• ••■ ••■ ••• •• •• J%X m 

§ I. Introduction ... ... ... ... ... ... ... ... ... i 

Definition of blindness and weak sight — Statistics of causes of blind- 
ness. 

Part I.— Eye Diseases of Hereditary Origin. 

§ 2. Inheritance of eye diseases 8 

§ 3. Inheritance of constitutional diseases 9 

Scrofula, tuberculosis, syphilis, leprosy. 
§ 4. Consanguinity of Parents 12 

Retinitis pigmentosa — Legislation respecting consanguineous marriages. 

Part II.— Eye Diseases of Childhood. 

§ 5. Scrofulous eye affections 17 

Their frequency — Holiday colonies — Sanatoria at the sea-side and at 
baths. 

§ 6. Other eye affections arising from general diseases 22 

Keratomalacia. 

Part III.— Eye Diseases incident to the Edncational Period. 

Chapter I.— Causes of Myopia. 

§ 7* Congenital myopia ... ... ... ... ... ... ... ... 24 

§ 8. Acquired myopia ... ... ... ... ... ... 25 

Refraction of new born infants — Of uncivilized peoples — Of various 
classes of occupations. 



XIV. CONTENTS. 



PAGE 

§ 9. Sbort-siglbtedcess in Schools 28 

Town and Upper Schools — Increase of the number of Myopes with 
the class — Increase of the d^ree of Myopia — Examination of the 
same scholars at dlfierent limes. 

§ 10. Circnmstances which favour the occurrence of Myopia ... 32 

Heredity — Myo(na in the female sex — Nationality. 
§ II. Blindness as a consequence of Myopia 35 



Chapter II. — Prophylaxis of Myopi.a. 

I. General Measures. 
(a). Measures relating to tlie School-room, 

§ 12. Illumination ... ... ... ... ... ... ... ... ... 37 

Influence of the illumination on Myopia — Methods of measuring the 
illumination. 

§ 13. Position of the school-house 40 

To which point of the compass should the windows look ?^ Aspect of 
the building — Neighbouring buildings. 

§ 14. Position of the Windows 43 

Skylight — Lighting from one side — Height of windows — L^hting from 
both sides — Height of the window-sill — Relation of the window 
surface to the floor surface — Walls of the school-room — Warding 
off the direct sunlight. 

§ 15. Artificial Illumination 49 

Gas light — Electric light. 
§ 16. Scats and Desks ... ... ... ... ... ... ... ... 50 

W^orking distance — Proper position of the body — Construction of seats 
and desks — Upright holder. 

{b). Measures affecting the scholars, 

^H m 1 9 V V A XWAXJl^ ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ^^ 

Physiology of the handwriting — Upright handwriting — Sloping hand 
writing — \Vhich is to be preferred ? — Influence of the Teacher — 
Writing characters — Stenography. 

^ JIO« jXCrClClllUl • •• ••• ••• ••• ••• ••• »•• ••• ••■ ••• \j^^ 

Visibility and legibility of the letters — Thick strokes and hair strokes 
— Form of the letters — Influence of practice — Good type — Paper. 

§ 19. Drawing and manual work 63 

§ 20. Lighting in Home-work ., 64 



CONTENTS. XV. 



II. Special measures for the different stages of Education. 

PAGE 

§ 21. Primary Education ... ... ... ... ... ... 65. 

Age at which a child should commence school — Duration of school 
lessons — Pauses in teaching — Distribution of lessons — Methods of 
Instruction — ^Writing material. 
§ 22. Middle school Education ... ... ... ... ... 68- 

Over working of scholars and its causes — Diminution of the school les- 
sons — Their duration and distribution — Home-work — Holidays — 
Education of youth in general — Upper school education. 



III. Measures applicable to existing Myopia. 
§ 23. Use of concave spectacles 74 

IV. Medical Supervision of Schools. 
§ 24. Measures adopted by Governments and Towns for the supervision of 

dLrlll./vld ••• ••• ••• ••• ••• ••• ••• ••• ••• ^ ^ 

§ 25. School Doctors... ... ... ... ... ... ... ... ... 7^ 

Requirements for an efficient control of schools — What kind of medical 
practitioners are required for schools? — Regulations for medical 
supervision of schools. 

Part IV.— Eye Diseases consequent on General Diseases. 
Chapter I.— Acute Febrile Diseases. 

§ 26. Affections of the Cornea Z"^ 

Keratitis xerotica — Corneal abscess in small-pox — Vaccination — Treat- 
ment of the eyes of small-pox patients. 

§ 27. Affections of the Uveal Tract %% 

Febris recurrens — Cerebro-spinal meningitis — Pyoemia. 

§ 28. Affections of the Optic Nerve 91 

Chapter II. — Chronic Diseases. 

§ 29. Chronic general diseases 92 

Syphilis. 

§ 30. Chronic diseases of organs 94. 

§ 31. Derangements of nutrition of unknown kinds 94 



xvi. CONTENTS. 



Chapter III.— Chronic Poisoning. 

PAGE 

§ 32. Tobacco poisoning 9^ 

Nicotine — Consumption of tobacco — Prophylaxis. 
§ 33. Alcoholic poisoning 99 

Consumption of spirits — Measures for the prevention of abuse of 
alcohol. 
§ 34* Le^d poisoning... ... ... ... ... ... ... ... ••• 102 

Causes —Prophylaxis. 

Part v.— Infactions Eye-Diseases. 

(a). Blennorrhoic conjiuutivitis. 

Chapter I.— General Characteristics of Blennorrhoic 

Conjunctivitis, 

§ 35. Forms of blennorrhoic conjunctivitis • 104 

Their cetiological identity — Connexion between acute and chronic 
forms — Gonococcus. 

§ 36. Modalities of infection ... ... ... ... ... ... ... 108 

Piringer's experiments— Infection through the air. 

Chapter II.— Blennorriicea Neonatorum. 

§ 37. Infection during birth ill 

Process of infection —Intra uterine infection— Virulent and catarrhal 
vaginal secretion— Period of incubation. 

§ 38. Infection after birth 113 

By the lochial secretion— By an eye affected with blennorrhoea— Other 
causes of infection. 

§ 39. Frequency of blennorrhooea neonatorum 115 

In lying-in and foundling hospitals— Among the public. 

§ 40. Dangers of blennorrhoea neonatorum 117 

In lying-in and foundling hospitals— In eye hospitals — Blindness of 
both eyes — How much does blennorrhosa neonatorum contribute 
to the total number of the blind. 

§ 41. Prophylaxis of blennorrhoea neonatorum I2I 

Gibson's proposals. 

§ 42. Prevention of infection during birth 123 

Disinfection of the maternal passages— Disinfection of the infant's eyes. 

§43. Results of the prophylactic methods 126 

Comparison of the different methods — Mode of action of nitrate of 
silver. 



CONTENTS. xvii. 



PAGE 

§ 44. Prophylaxis of blennorrhoea neonatorum outside lying-in hospitals ... 131 
Can midwives be trusted to do it ?— Eversion of the eye-lids — Instruc- 
tion of the publics-Directions of the sanitary authorities. 

§45. Prevention of infection after birth 134 

By the bath water— By the lochial secretion — By the nurses— By dis- 
eased infants — Prophylaxis in foundling hospitals. 

§ 46. Treatment of blennorrhoea neonatorum 135 

Good results of treatment — Treatment in lying-in hospitals — In found- 
ling hospitals-^Treatment outside these establishments— Obliga- 
tory notification by midwives — Protection of the second eye. 

§47. Carrying out the prophylaxis 13^ 

Regulations for midwives — Instruction for midwives. 



Chapiter III.— Blennorrhcea Acuta Adultorum. 

§ 4^* -Etiology ... ... ... ... ... ... ... ... ... 142 

Infection by secretion from the genitals — By the discharge from 

diseased eyes — Frequency of acute blennorrhcea. 
§ 49* Prophylaxis ... ... ... ... ... ... ... ... ... 144 

Cleanliness — Prophylaxis in the l)dng-in and foundling hospitals — 

Whilst treating blennorrhoic patients. 



Chapter IV. — Trachoma. 

§ ^o, i^tiology ... ... ••• ••• ••• ••• ••• >•• ... 14^ 

Trachoma has existed in Europe for ages — Besides infection are there 
any o'ther causes of trachoma?— Circumstances which favour infec- 
tion — Wars — Crowding of dwellings — Foul air — Examination of 
school children. 
§ 51. Trachoma among soldiers ... ... ... ... ... ... ... 150 

Epidemic of trachoma at the commencement of this century — Re- 
ciprocal communication. 

§ $2. Trachoma among civilians ... ... ... ... 152 

Institutions with boarders — Ship's crew— Influence of age — Of pecuni- 
ary circumstances. 
§ 53. Geographical distribution ... ... ... ... ... ... ... 154 

Europe — Extra European Countries— Climate — Race. 
§ 54. Dangers of trachoma ... ... ... ... ... ... ... ..« 157 



XVIU. CONTENTS. 



PAGE 

§ 55. Prophylaxis of trachoma in the army 158 

Military surgeons — Recruiting — Barracks — Medical inspection — Dis- 
charge from trachomatous eyes — Dismissal from the service — 
Proposals for the prophylaxis : (a) or countries with much 
trachoma ; (b) with little trachoma. 

§ 56. Prophylaxis in civil establishments ... 164 

Establishments with boarders— Seclusion of the trachomatous— Day 
scholars — School doctors. 

§ 57. Prophylaxis among the general civil population 168 

Compulsory notification. 

{b). Diphtheric conjuttctivitis, 

§ 58. Origin of diphtheria— Epidemics of Diphtheria — Geographical distribu- 
tion — Danger— Prophylaxis 170 



Part VI.— Influence of the Occupation on Eye Diseases. 

§ 59. Non-traumatic eye affections 174 

Myopia — Abscess of cornea. 

^ Vw« X III U iXCO ••• ••• ••• ••», ••• ••• ••• att ••• ••« ^// 

Frequency— Causes — Injuries by burning — By foreign bodies— By ex- 
plosions — By thrust, blow, &c. — Injuries received in war. 
§ 61. Prophylaxis of injuries 184 

Regulations for factories— Protective spectacles —Factory work of 
children —Dangerous toys — Treatment of injuries — Precautions 
for workpeople— Sympathetic ophthalmia. 



Part VII.— Inflnenoe of Social Conditions on Eye Diseases. 

■§ 62. Influence of degrees of culture 189 

Cleanliness — Nutrition — Factory work of children — ^Dwelling. 

<§ 63. Lighting ... ... ... ... ... ... ... ... ... 192 

Brightness — Dazzling — Steadiness — Colour — Production of heat — 
Direction whence the light falls — Deterioration of the air — Cost. 



Part VIII.— Influence of Climate and Race on Eye Diseases. 

§64. Decrease of the blind as wc go north 201 

Sea-coast and hilly regions— Race. 



CONTENTS. 



XIX. 



Fart IX.— Treatment of Eye Diseases. 



••• •••• ••• ••• ••• ••• 



PAGE 
203 



§ 65. Enlightenment of the people ... 
Instruction in hygiene. 

§66. Education of medical men in ophthalmic medicine 205 

How far should it be carried ? — Ophthalmological teaching in the Uni- 
versities of Europe. 

§ 67. Eye dispensaries , 217 

Intervention of the State in their establishment — Rights and duties of 
the directors of dispensaries — Dispensaries in large towns. 

§ 68. Organization of the sanitary authorities 222 

Duties of the chief sanitary authority. Their actual organization in 
European countries. 

x^V/Alwl UdXvI A ••• ••• ••• ••• t»« ••• ••• ••• ■•• ••• w^ i 

231 
232 
238 
243 
. 244 



Appendix No. i, by Dr. Dudgeon 
Appendix No. 2, by Dr. Roth 
•Glossary of Technical Terms... 
Diagram of Eye 

XUUwA •«• ••• • • % ••• 



INTRODUCTION. 



§ I. This work has an essentially practical aim. The causes 
of blindness will be investigated in order that they may be com- 
bated, and thereby the number of cases of blindness diminished. 
For our purpose, we shall include in the term blindness more 
than we would if our investigation were strictly scientific. Ex- 
treme degrees of weak sight interfere with the working powers 
just as much as complete blindness, so that the subjects of them 
are rendered miserable and become a burden to others. 

In a scientific sense the eye, which 'is incapable of the objec- 
tive sensation of light is blind (amaurosis). This blindness is of 
one eye or of both ; it is (with very rare exceptions) incurable. 
In a scientific sense an eye which can in no way attain to a 
normal sharpness of vision, is weak-sighted. In conformity with 
this definition, science calls weak-sighted some persons who- 
do not consider themselves to be so, e.g,y persons with defects of 
refraction that cannot be completely corrected. On the other 
hand, it calls normal-sighted, for instance, a person affected 
with an extreme degree of myopia, if he can obtain perfect 
sharpness of vision by instrumental aid, though he may, perhaps, 
consider himself to be weak-sighted if his occupation prevent 

him wearing glasses. 
I 



DEFINITION OF BLINDNESS. 



For our practical purpose we shall choose the term for the 
defect of vision according to the amount of hindrance to work- 
ing for his livelihood it inflicts upon the subject of it. We call 
a person blind whose visual power is so diminished in an irre- 
mediable manner that he is unable to follow any occupation re- 
quiring the use of the eyes. It is not of so much consequence 
what amount of vision still remains ; the important point is, that 
every individual who is blind in this sense, cannot support himself, 
but needs the aid of his fellow-man. — The above definition re- 
quires further elucidation. 

1. The definition takes no notice of the fact that really blind 
persons may, by receiving appropriate instruction, or by their 
own practice and dexterity, get so far as to be able to exercise a 
calling, which, under ordinary circumstances, requires the use of 
the eyes. 

2. The definition excludes all cases of blindness of one eye 
only and all curable cases. A considerable number of curable 
cases is put down in the official statistics as blind ; they are 
sometimes even met with as pupils in institutions for the blind.* 

The best practical test of blindness is given by the capability 
of finding one's way about. According to this, any one must be 

* Some of these cases, indeed, occasionally possess pretty good powers of 
vision. I once operated on a boy, a pupil of the Vienna Institution for the 
Education of the Blind, for trichiasis. In consequence of this affection he 
had such extreme photophobia that he could not go about by himself, and 
was reckoned as blind. But with the exception of a slight dimness of 
the cornea, the eyeballs were normal. If for any reason such a case can- 
not be cured, it must be pronounced practically blind, even though the eyes 
may be capable of seeing. 



ABILITY TO FIND ONE'S WAY ABOUT. 



denominated blind who is unable in good daylight to guide 
himself about alone. I say " in good daylight," in order to ex- 
clude the subjects of hemeralopia, who see well by day, and are 
only unable to find their way about by night. The inability to 
find one's way alone only refers to places with which the 
patient is unfamiliar. In his own house almost every blind per- 
son can find his way about. 

Of authors who have concerned themselves with the defini- 
tion of blindness, some {e.g.y Emmert)* have accepted the im- 
possibility of finding one's way about as constituting blindness. 
Others have, in opposition to this definition, adduced instances 
of persons totally blind who yet could find their way about. On 
the other hand, they allege that it is not blind but only imf)er- 
fectly seeing persons who are unable to go alone, because at the 
same time the hearing, the sense of touch, the mobility of the 
legs, &c., are not perfect. No doubt this is so, but the true state of 
matters must always be easily ascertained. Moreover, such persons 
are assuredly unable to follow any occupation, even though they 
may possess somewhat more power of vision than could be pre- 
dicated of them from their inability to find their way about. 

The inability to find their way about is very suitable as a 
criterion of blindness, for, as a rule, such persons for that cause 
alone are incapacitated from exercising an independent calling. 
Moreover, the fact that a person requires to be led about is 
known to his neighbours, and hence is easily ascertained. 
Thereby investigations relative to blind persons, detection of im- 
ixjstors, &c., are facilitated. 



* Correspondenzblatt fiir Schweizer Aerzte^ 1874, iv., No. 21, etseq. 



WEAK SIGHT. 



We may, probably, take for granted that a person who can 
count fingers held at a distance of 40 inches stands at the limit 
of being able to find his way about Any one who cannot do 
this is, as a rule, unable to go about alone. I do not differ 
greatly from what SCHMIDT- RiMPLER* and MAGNUSf accept as 
the limit of blindness. These writers regard an individual as 
blind, who is only able to count fingers at 12 inches at furthest, but 
they admit that such a person may eventually count fingers at 
a greater distance under peculiarly favourable conditions of 
illumination. 

Those who, on account of their defective vision, are incapaci- 
tated for certain callings, are weak-sighted in a practical sense. 
Such individuals only exceptionally become dependent on others 
for their support. If the weak sight was already present when 
he was quite young, the subject of it would be set to coarser 
kinds of work, and would earn a smaller income than he could 
have earned considering the state of his other faculties. When the 
weak sight only comes on at a later period, it often compels its 
subject to take up another employment. The older he is when he 
becomes affected by weak sight, the less fitted is he for a change 
of occupation, and the more apt is he to become quite incapaci- 
tated from working for his bread. Thus weak sight is a relative 
term dependent on the demands which the special employment 
makes on the visual faculty. 

The statistics of blindness which we at present possess are 

* Ueber Blindsein^ Deutsche ^ifr^^m, Breslau, 1882. 
t Magnus, Die Blindheit^ ihre Entstehung und ihre Verhiitung^ Breslau, 
1883. 



STATISTICS OF BLINDNESS. 5 



compiled on the basis of the census of population. The data 

of population censuses are naturally not quite accurate. Ze- 

HENDER* has examined these data for the Gran^ Duchies of 
Mecklenburg. He found that many blind persons were not 

counted as such, whilst on the other hand some who could see 

were put down as blind. In the census returns no accurate 

distinction, as may well be imagined, was made between blindness 

and a high degree of weak sight ; nor yet between curable and 

incurable blindness. 

* For our purpose the statistics of the causes of blindness are of 

more importance than the general statistics of blindness. These 

are, of course, much more difficult to be obtained. In order 

to ascertain the causes of blindness the blind person must 

be examined by an oculist. But in many cases it is difficult, 

or impossible, for even an oculist to ascertain the cause of a 

blindness of long standing. Hence, the statistics relating to the 

causes of blindness hitherto published embrace a proportionately 

small number of cases. For Germany, we depend chiefly on the 

statistics of COHNf and MAGNUS; J both these authors will be 

frequently quoted in the course of our work. In France 

FlEUZAL and Daumas, in Spain Carreras-Arago, in Russia 

Krueckow and Skrebitzky, have furnished statistics of the 

causes of blindness. 

* Zehender's Klin, Monatsbldtter, 1870, p. 277. 

t EuLENBURG'S Realenclyclopddte der gesammten Heilkunde, Artikel 
Blindenstatistik, 

X Loc. cit. Both these authors base their compilations partly on their 
own statistics, partly on the investigations of Schmidt-Rimpler, 
Stolte, Uthoff, Hirschberg, Landesberg, Bremer, and Katz. 



corn's and MAGNUS'S STATISTICS. 



I subjoin the statistics of COHN and MAGNUS. The former 
are given by Seidelman.* They refer to i,ooo cases of blind- 
ness taken from the case-books of Cohn's eye clinic. The 
blindness was of both eyes in 224, of one eye in 552 cases. 



I. Congenital defects of structure 9 

II. Glioma retinae 6 

III. Blennorrhoea neonatorum ... Ill 



IV. Iftflammations incurred later 166 


,, of conjunctiva — 


„ of cornea 


.- 39 


„ of iris & choroid 28 


Sympathy without 


injury 


... 4 


Doubtful origin 


• • • 


— 


Scrofula 


• • • 


... 7 


Gonorrhoea ... 


• • • 


... 26 


Iritis spec. 


• • • 


... 9 


Chorioiditis spec. 


• • • 


... II 


Trachoma 


• •« 


... 17 


Keratomalacia 


• • • 


... 8 


Diphtheria 


• • • 


- 3 


Puerperium ... 


• • • 


3 


V. Wounds 


• • • 


...242 


Both eyes 


• • • 


... 10 


Sympathy after wound 


... 9 



VI. Acute exanthema 

Small-pox 

Measles 

Scarlatina 

VII. Typhus 

VIII. Sublatio retinae 

Ex myopia 

Idiopathica 

IX. Retinitis 

Centralis e myopia .. 

Albuminurica 

Neuroretinitis 

Pigmentosa 

Chorioretinitis 
X. Atrophia nervi optici 

Cerebralis 

Spinalis 

Ex alia causa... 

XI. Glaucoma 

XII. Tumores bulbi 

10 XIII. Operationes infaustae 

XIV. Various causes 



54 

36 
14 

4 
9 

73 

46 

27 
84 

46 

2 

7 

9 

3 
102 

30 

19 

53 
88 

14 

22 

81 



Magnus, in his arrangement of 2,528 cases, admits only- 
cases of blindness of both eyes, because in the practical treat- 
ment of the blind question they alone are to be considered. In- 
stead of giving Magnus's tables in exUnso, I will refer the 
reader to Roth's coloured reproduction of MAGNUS'S graphic 
representation which will be found at the end of this book. 



* Zur Aetiologie und Prophylaxis der Erblindungen, Inaug.-Dissert. 
Breslau, 1876. 



Part I. 
Eye Diseases of Hereditary Origin. 

§ 2. The eye diseases which are of hereditary origin either 
exist at the time of birth — congenital eye diseases — or they first 
make their appearance at a later period of life. Hence, all 
hereditary eye diseases are not congenital, just as all congenital 
eye affections are not hereditary. 

As regards congenital eye affections, we rarely find at birth 
the morbid process in its active state. As a rule, we have to do 
with the effects of foetal diseases, opacities of the cornea and lens, 
closure of the pupil, atrophy of the internal membranes or of 
the optic nerve, distension or diminished size of the whole eyeball. 
The diminution of the eyeball can amount to its seeming com- 
plete absence — anophthalmus. In how far deformities of the 
eye are the remains of fcetal inflammations, or the consequences 
of arrest of growth, further investigations must teach us. To the 
slighter congenital defects of the eye belong certain deformities 
of the eyeball, such as congenital hypermetropic or myopic shape 
and astigmatism. 

The hereditary eye affections which are not already present 
at the period of birth have a latent existence, merely giving a 



8 INHERITED EYE DISEASES. 



tendency to disease. The disease breaks out in consequence 
of external injury, or even without any such cause. To these 
hereditar}' diseases belong many cases of myopia, cataract, 
glaucoma, &c. The hereditary character of retinitis pigmentosa 
and certain forms of neuritis is generally acknowledged. 

To the class of inherited eye diseases, in the wider sense of 
the term, belong those cases in which the parents convey to their 
offspring a general dyscrasia (scrofula, tuberculosis, syphilis, 
&c.), thereby laying the foundation for various eye affections. 
Finally, there are cases of inherited eye affections which are 
owing, not to a disease, but to the blood-relationship of the 
parents. — ^We must now consider more in detail these three 
categories of hereditary eye affections. 

I. Eye diseases of the parents are transmitted to the offspring. 
— As already stated, the inherited eye affection in children is 
either present at birth, or develops itself later. 

As a rule, the eye affection of the children is not always quite 
identical with, but is analagous to, that of the parents. There 
are, however, exceptions to this. Thus, a man who had lost his 
sight by blennorrhoea neonatorum had two children affected 
with microphthalmus (MAGNUS). I am acquainted with a 
physician who has congenital microphthalmus of the right eye. 
His father lost his eye when a child by iridocyclitis. The con- 
nexion of the eye disease of father and child is indubitable, for 
Deutschmann obtained analogous results in his experiments on 
rabbits. 

As regards the inherited eye diseases, there is no question of 
prophylaxis, properly so called. We possess no means of pre- 



INHERITED CONSTITUTIONAL DISEASES. 



venting the transmission of certain eye affections from parents 
to their offspring. It could only be prevented by those affected 
with such maladies denying themselves offspring. But that, of 
course, cannot be expected. But the physician may warn such 
persons when about to marry that they may possibly have chil- 
dren affected with diseases of the eye, or blindness. What are 
the cases in which such a result is particularly to be feared ? 
Those cases in which the parents themselves are suffering from 
an eye disease, either congenital or incurred at an early age. 
Magnus has investigated fourteen instances of married couples, 
in whom one or both members were either born blind or became 
blind at an early age. Of the thirty-four children begotten of 
these marriages, 8=23*5 °/^ were either blind or weak-sighted. 

§ 3. — 2. Constitutional diseases of patents are transmitted to 
their offspring, and in the latter become the cause of eye diseases. 
— ^The constitutional diseases here referred to are chiefly scrofula, 
tuberculosis, syphilis and leprosy. Among these scrofula holds 
the first place, as it most frequently gives rise to eye diseases. 
Horner* says that the diseases of the cornea, conjunctiva and 
lids together constitute 59°/^ of all the eye diseases of childhood. 
We know that children's affections of the conjunctiva and cornea 
mostly belong to the phlyctenular form, and their diseases of the 
lids to blepharitis. But as a rule, these forms of disease are of 
scrofulous origin. 

The influence of tuberculosis cannot be sharply divided from 
that of scrofula. Tuberculous parents have often scrofulous 

* Handbuch der Kinderkrankheiten^ herausg. von Gerhardt. Bd. V. 
Abth. ii., p. 203. 



10 HEREDITARY SYPHILIS. 

children. True tuberculous diseases of the eye do not come 
within the sphere of our consideration, as they are extremely 
rare and, as a rule, are quite insignificant in comparison with 
the general affection of the patients. 

Hereditary syphilitic eye affections were, for a long time, con- 
founded with scrofulous. It is only within the last ten years 
that any considerable progress has been effected in our know- 
ledge of these forms. Besides diseases of the deep seated parts 
of the eye, we ought particularly to mention here keratitis 
interstitialis (sive parenchymatosa). According to COHN* this 
disease constitutes 0.38°/^ of all eye diseases. To the eye 
diseases of childhood it contributes, according to HORNER,o.5''/^. 
The majority of cases belonging to this category are attributable 
to hereditary syphilis. 

What can be done to prevent hereditary syphilis ? A person 
infected by syphilis can never know for certain if he is completely 
cured of his syphilis, consequently he cannot know if he will 
beget healthy children. But the probability of his getting 
healthy children is greater, the longer the time that has elapsed 
since the last manifestations of syphilis. It is the physician's 
business to warn his syphilitic patients against marrying too soon. 
FoURNlERt has admirably stated the conditions under which 
alone the physician should give his consent to the marriage of a 
syphilitic : I. at the time of the marriage there should exist no 
localizations of syphilis which can be considered contagious, and 
cause an infection of the other party to be apprehended ; 2. at 

♦ Schubert, Ueber syphilitische Augenleiden^ Berlin, 1880. 
t Syphilis et Mariage^ Paris, 1880. 



ITS PROPHYLAXIS. II 



least three years should have elapsed since the infection, if the 
syphilis has run a favourable course, otherwise a still longer 
period ; 3. at least one and a half to two years should have passed 
without any fresh manifestations of syphilis ; 4. if the syphilis 
present a malignant character which shows itself in frequent 
relapses, inefficacy of treatment, early or serious visceral disease, 
considerable diminution of nutrition, or in any other manner,, 
the marriage should be delayed or broken off altogether ; 5. in 
every case of marriage a radical antisyphilitic treatment should 
first be undergone. 

Even strict attention to these precautionary rules, gives no 
guarantee that the children will be healthy. Even when they are 
quite healthy at birth, they may be affected by syphilitic disease 
later on. The most frequent form of hereditary syphilitic eye 
disease, interstitial keratitis belongs to the retarded form of 
syphilis. It comes on most frequently betwixt the ninth and 
sixteenth years of life, sometimes still later. 

When a woman during her pregnancy presents florid signs 
of syphilis, an energetic antisyphilitic treatment of her has a 
favourable effect on the foetus also.* The offspring of a marriage 
of syphilitics are often delicate and backward, but do not neces- 
sarily show specific symptoms. In such cases a tonic treatment 
particularly with remedies containing iodine is most fitted to 
prevent the development of keratitis interstitialis. 

♦ Thurmann relates the following : a sjrphilitic woman, who was not 
treated medically, bore successively seven children, who all died of syphilis. 
During her eighth and ninth pregnancy she was treated medically, and bore 
two healthy children. During her tenth pregnancy the treatment was 
neglected, the child died in six months of syphilis. In her eleventh 
pregnancy, the treatment was resumed and a healthy child was born. 



12 LEPROSY. 



Eye diseases arc among the most frequent complications of 
leprosy. According to Danielsen* out of 125 leprous patients 
Zj (= 69*/ j had eye diseases. Leprous eye diseases often 
result in blindness from opacity of the cornea or from the forma- 
tion of leprous tubercles in the cornea and sclera, which terminate 
in shrivelling up of the eyeball. Hence it comes that a large 
proportion of leprous subjects go blind before they die. In 
countries where leprosy prevails, a considerable number of the 
cases of blindness is due to this disease ; thus in Norway the 
proportion is 24°/^ (HjORT). • 

In mediaeval times, when leprosy was much more exten- 
sively prevalent than now, in many places there were strict 
rules for the isolation of patients, who were relegated to special 
lazar-houses. These rules were superfluous, for almost all 
observers are agreed that leprosy is not contagious. On the 
other hand it appears that it can be transmitted to the offspring. 
Danielsen and BOECKf have been able to trace the influence of 
heredity 185 times in 215 cases of leprosy, whereas Hebra 
denies the hereditary character of the disease. In Iceland, a law 
of the year 1776 forbids the leprous to marry ; no such law exists 
in Norway. As the hereditary character of the disease is not 
generally acknowledged, such a law can hardly be justified, 
irrespective of the circumstance that it cannot be reconciled with 
our modern notions respecting personal liberty. 

§ 4. — 3. Consanguinity of parents is a frequent cause of diseases, 

• Beretning om Lungegaardshospitalets Virksomhedy 1877-79. 

t Iraiti de la Spedalsked^ translated into French by CossoN, Paris, 1848. 



CONSANGUINITY OF PARENTS. 1 3 

among which I may mention especially, mental diseases, deaf- 
mutism and blindness. The latter is in most cases the result of 
retinitis pigmentosa. — The opinions regarding the influence of 
consanguinity on the offspring are by no means agreed. Not 
only have different explanations of this been offered, but there 
IS as yet no agreement about the fact itself. The so-called 
consanguinists deny that blood-relationship has an unfavourable 
influence on the children. G. Darwin* sought to prove that in 
England the number of imperfect (particularly deaf-mute) 
children is not greater in marriages of consanguinity than in other 
marriages. — Hence we must in the first place endeavour to get at 
the facts, and especially as regards retinitis pigmentosa. The 
data obtainable on this p6int are very scanty, for most of the 
statistics relative to the question of consanguinity refer to 
deaf-mutism and not to blindness. The data regarding 
retinitis pigmentosa were collected in two different ways. Some 
authors (LlEBRElCH, Hocquard) examined the pupils of deaf 
and dumb institutions, bearing in mind that retinitis pigmentosa 
is frequently met with among deaf-mutes. It was shown that 
many of the subjects of retinitis were the offspring of con- 
sanguineous marriages. But the results thus obtained are not 
convincing, if it be true that deaf-mutism is a frequent conse- 
quence of the consanguinity of the parents. We should then 
naturally find frequently among deaf-mutes affected with retinitis 
blood-relationship of the parents. — Other data are the cases of 
retinitis pigmentosa which presented themselves in a certain eye- 

* Journal of the Statistical Society^ June, 1875. 



H 



RETINITIS PIGMENTOSA. 



clinic in the course of a considerable period. I give here 
some of the records on this subject : 



Authors. Cases of retinitis pigm. From consanguineous marriages. Per c( 


FlEUZAL* 


• •• 21 ... ••• o •*. 


... 38 


MOORENt 


• •• •*. ... "~"~ • . • 


... 33 


Leber t 


• « • oo ••• ••• lo •*• 


27 


Saemisch § 


• • . \j\j ••• ••• xs ••• 


25 



These statistics are corroborated by numerous single ob- 
servations. Thus, for example, FlEUZAL has the following : In 

Paris there is a married couple who are cousins. They have had 
fourteen children ; of these eight died in earliest infancy, so that 
nothing is known respecting the condition of their eyes. All the 
other six were either blind or very weak-sighted. In some of 
them FlEUZAL was able to ascertain the existence of retinitis 
pigmentosa. 

In order to make these statistics available as evidence, they 
must be compared with the proportion of consanguineous 
marriages to other marriages. I shall take the data for this 
point from the French statistics, which for many years have 
specially recorded the marriages of blood-relations. I shall 
only consider here marriages between nephew and aunt, 
uncle and niece, and between the children of brothers or 



* Dictionnaire encyclop, des sciences mcd, de Dechambre. T. XIX. Art. 
Consanguinity, 

t FiinJLustren ophthalmologischer Wirksamkeit^ Wiesbaden, 1882, p. 219- 
I Handbuch der Augenheilk, von Grdfe-Sciinisch. Vol. V., p. 654. 
§ Derigs, Ueber Retinitis pigmentosa^ Bonn, 1882, p. 21 ; 



MARRIAGE LAWS. 1 5 



sisters, but not marriages between more distant blood-relations. 

In France the number of consanguineous marriages was 

in 1853 59 = 0.9% of all marriages 

in 1 861 74=1.2% „ * 

Now if retinitis pigm. had nothing to do with consanguinity 
then not 25 to 38°/^ but only about 1°/^ of the cases in question 
would be derived from consanguineous marriages, fewer indeed, for 
such marriages are usually unfruitful. Retinitis pigm., therefore, 
is about thirty times more frequent in the children of con- 
sanguineous marriages than in other children.f 

The laws which for ages have imposed limits on the matri- 
monial alliances of blood relations, were doubtless suggested by 
the experience that such alliances were unfavourable for the 
offspring. I subjoin the laws adopted by the more important 
states of Europe relating to consanguineous marriages : 

1. In Russia the secular is framed in accordance with the 
canon law, and marriages up to the seventh degree of consan- 
guinity are forbidden.t 

2. Marriage is forbidden betwixt relations of the third degree 



♦ BoUDiN, Ann. d'hygi^ne publ. 2 serie, T. XVIII. 

t I do not conceal from myself the inadequacy of the above statistics. 
The proportion of consanguineous marriages to other marriages is only that 
obtaining in France, whereas the cases of retinitis pigm. are taken partly 
from French, partly from German records. As' a rule consanguineous 
marriages are rarer in Germany than in France. Moreover the statistics of 
retinitis pigm. deal with too few numbers — on account of the rarity of this 
disease. I am therefore very far from regarding the figures given as con- 
clusive, still they certainly show the influence of consanguinity. 

J RiTTER, Oesterreich, Eherecht Leipzig, 1876. 



1 6 MARRIAGE LAWS. 



(uncle and niece, aunt and nephew) and of the fourth degree 
(children of brothers and sisters) in Austria* and in Swit2erland.f 

3. Marriage is forbidden (or only permitted by dispensation) 
between relations of the third degree, but permitted between 
relations of the fourth degree in England,^ France,§ ItalyJI 
Holland,ir and Roumania. 

4. In Germany marriage is only forbidden between relations 
in ascending and descending line, and between brothers and 
sisters, but allowed between relations of the third and fourth 
degrees.** 

Thus we perceive that the laws vary much in different 
countries ; those of Russia and of Germany are the two 
extremes. — In the above I have omitted the regulations con- 
cerning marriage between brothers and sisters-in-law as they 
possess no medical interest. I will only observe that many of 
the laws on this subject contain unjustifiable contradictions, as 
for instance, the English laws, which on the one hand allow 
marriages between first cousins, but forbid marriages between 
brother-in-law and sister-in-law. 

Cases of retinitis pigm. are so rare that it would not be 
proper to forbid marriage between blood-relations on this account 
alone, that is to say 1°/^ of all marriages. It is different with 

* Par. 65 of the BUrgerL Gesetzbuch, For Jewish subjects the marriage 
of the children of brothers or sisters is allowed. 

t Loi fdderale. Par. 28. 

X Stephen, New Commentaries on the Laws ofEnglandy London, 1844. 
Vol., II. p. 284. 

§ Code civile § 163. || Code civile § 58. IT Code civile § 88. 

•* Deutsches Reichsgesetzbuch^ § ZZ- 



EYE DISEASES OF CHILDHOOD. 1 7 

respect to the so much more frequent deaf-mutism, some mental 
diseases, &c., in so far as they may be dependent on the consaa* 
guinity of parents. But the determination of this question is 
out of place here. 



Part 11. 



Eye Diseases of Childhood. 

§ 5. These consist partly of local affections of the eye, 
partly of the sequelae of general diseases. Of the former, 
some are referable to infection, others are of spontaneous origin. 
Of infectious eye diseases, I may mention the blennorrhcea of 
new-born infants and diphtheria. Both of these will come 
under consideration when treating of the analogous diseases of 
adults. I will also consider, later on, trachoma, &c. 

The purely local eye diseases, not dependent on infection, 
to which children are liable, are seldom so dangerous as to lead to 
blindness. It is otherwise with injuries, which will be treated of 
hereafter. 

The most frequent eye diseases of children are those which 
are the consequence of a general dyscrasia. Among these the 
most important is scrofula. 

Scrofula localises itself in the eye as conjunctivitis and kera- 
titis phlyctaenularis (pustulosa). In the great majority of cases 
these maladies occur along with other symptoms of scrofula, so 

that VON Arlt rightly denominates them conjunctivitis scrofu- 

2 



1 8 SCROFULA. 



losa. (Under this name, he comprehends the affection of 
the conjunctiva and cornea, for he regards the latter as a mere 
propagation of the disease from the conjunctiva of the sclera to 
the conjunctival layer of the cornea.) The consequences of 
scrofulous keratitis are opacities of the cornea, in the worst cases 
of such an extensive character that thereby almost complete 
blindness is produced. — Scrofula, moreover, causes diseases of 
the deeper seated structures of the eye, such as iritis, iridocyclitis 
and chorioiditis, as also a peculiar kind of keratitis paren- 
chymatosa. Indirectly, scrofula endangers the eye by setting up 
disease of neighbouring structures. Obstinate blepharitis leads to 
inflammation of the conjunctiva and cornea. Caries of the orbital 
bones is a frequent cause of ectropium of the lids with its inju- 
rious effects on the cornea. 

Scrofulous eye affections very rarely lead to total blindness; 
COHN asserts that scrofula furnishes 7 per thousand, MAGNUS 
0'4 per thousand of all blind persons. BiRCH-HlRSCHFELD 
found in the Saxon blind asylums only 67o of cases of blind- 
ness from scrofula, though only young blind subjects are admitted 
into these asylums. If complete blindness from scrofula is rare, 
it is a frequent cause of weak sight Almost all opacities of the 
cornea met with in young subjects are the result of scrofulous 
ophthalmia. COHN found among 10,060 school-children whom he 
examined, 2 °/^ affected with corneal opacities. 

Scrofulous ophthalmias do much harm in consequence of their 
liability to frequent relapses, sometimes lasting through the whole 
period of childhood, whereby their victims must suffer seriously 
in their education and training for trades. 



HOLIDAY COLONIES. 1 9 



Apart from its effect on the eyes, scrofula causes so many 
other ailments, and is, moreover, so extensively prevalent that it 
must be looked upon as one of the worst scourges of humanity. 
The eradication of this plague is one of the noblest tasks of the 
philanthropist 

The only effectual prophylaxis against scrofula is the improve- 
ment of the circumstances of the lower classes. With an increase 
of the welfare of the people, their food becomes improved, 
and especially do they more frequently partake of butcher's 
meat Their habitations become more roomy and less crowded. 
The erection of well-built, dry, well-ventilated labourers' houses 
contribute much to this end. Cleanliness becomes more general. 
The children are more carefully looked after ; instead of being 
set too early to household or factory work, they are sent to re- 
ceive instruction at school. I can only cursorily allude to those 
points which belong rather to the province of the social politician 
than to that of the physician. Later on, I shall return to this 
subject. 

In cases of already existing scrofulous eye diseases, the 
treatment must be directed not only against the eye disease, 
but also against the general disease which lies at the root of it 
In this way only will the perpetual relapses which tend to de- 
teriorate the visual power be avoided. It is a great help to the 
medical treatment if we can bring the little patients, occasionally 
at least, into more favourable conditions of life. A good com- 
mencement for this purpose has been made by the establishment 
of holiday- colonies and sea-side stations. 

Holiday colonies do not receive sick, but only delicate chil- 



20 SEA-SIDE SANATORIA. 

dren ; their object is therefore mainly prophylactic. Pastor 
BlON, of Zurich, organised the first of these colonies (1878), and 
his example was soon followed by others in Switzerland, Ger- 
many, Austria and Italy. The children remain on an average 
one month in these colonies. The favourable effect of this 
sojourn in a healthy (often hilly) situation on the children is 
very evident. This has been proved objectively by weighing the 
children before and after their holiday outing. A continuance 
of the weighing during the subsequent school-year showed that 
the improvement in the state of health of the children was not 
merely transient* — A somewhat different plan was first adopted 
in Denmark. It consisted in sending the children during the 
holiday months to be boarded two or three together in well- 
regulated farmhouses. In many respects this plan is not so good 
as the holiday-colonies ; but, on the other hand, it has the in- 
estimable advantage of costing less, for the farmers will take the 
children and board them for a very small remuneration — often, 
indeed, gratuitously. Thus it was possible in Denmark for 7,000 
children to be sent in summer into the country in this manner 
during the last few years : whereas in all the holiday-colonies of 
Germany, Austria and Switzerland, from 1876 to 1881, only 
5,984 children could be received. Hamburg and Bremen have 
therefore begun to follow the example of Denmark. 

For really sick children, the sanatoria which have been 
established on the sea-coast and beside mineral waters of 
acknowledged efficacy in scrofula, are well adapted. 

* Varrentrapp, IVlme Congrh international d^Hygilne, Geneve 
1882. T. I., p. 160. . 



MINERAL SPRING SANATORIA. 21 

The oldest seaside station dates from the last century ; it is 
the National Hospital at Margate, on the English coast, which 
takes in 700 children annually. But the impetus to the founda- 
tion of this kind of sanitary institution of later years proceeded 
from Italy, and her example was soon followed by other Euro- 
pean States, as also by North America. Italy now possesses no 
less than twenty such establishments, which, however, arc only 
open for a part of the year. The sojourn of the children in them 
is on an average forty-five days. In France, on the other hand, 
the children remain from nine to twelve months in these stations. 
The establishments of the former kind are hence more suitable for 
slighter cases, those open all the year round for more severe 
cases of illness. Of course, the cases sent to these stations must 
be carefully chosen. As regards scrofulous inflammations of 
the eye, further observation is required to show the effect on 
them of a residence at the seaside and baths. It is indubitable 
that children who are sent to such stations after the cessation of 
an attack, return home strengthened, and less liable to relapses. — 
It is an excellent idea, first expressed by Michelet, if possible, 
not to allow the children cured in these sanatoria to return to 
town and their former surroundings, but to send them to agri- 
cultural work, or to sea as sailors. 

There are sanatoria for poor children at many of the bathing 
places recommended for scrofula, particularly the brine baths,* 



• Uffelmann gives (Deutsche Vierteljahrsschriff f. Gesutidheitspjlege 
Bd. XII,, p. 704) a chart showing the sanatoria in Germany for poor chil- 
dren at the sea-coast, in the country, and at the brine baths. 



2 2 RICKETS. — KERATOM AL ACI A. 

and what I have said respecting sea-side stations applies equally 
to these places. They are less suitable for florid cases than for 
completing the cure of cases of scrofulous eye diseases already on 
the decline. 

§ 6. The other general diseases of childhood are of minor 
importance to scrofula as far as regards their influence on the eye. 
Rachitis may be the cause of lamellar cataract. Tuberculous eye 
affections are too rare to merit consideration in this place ; the 
same may be said of those having their origin in acquired 
syphilis. Hereditary syphilis is frequent among children ; these 
children are as a rule sickly, and their habitus as also the forms 
of disease they are liable to are so similar to scrofula, that the 
difference between the two diseases is not always easily made 
out. Fortunately this is of no great importance in a practical 
point of view, as a general strengthening treatment is usually 
more suitable than a strictly anti-syphilitic treatment. A sojourn 
in the sanatoria above alluded to is as efficacious for such chil- 
dren as for scrofulous children. 

Von Graefe* was the first to describe a peculiar kind of 
suppuration of the cornea as keratomalacia, incident to the general 
marasmus of children, which however he erroneously connected 
with encephalitis. He observed a simultaneous xerosis of the 
conjunctiva without attaching any particular importance to it 
COHNf was the first to point out this connexion; in all the 
severe cases of conjunctival xerosis he observed, there was a 



♦ V. Graefe's Archivf, Optkalmologiey Bd. XII., 2 Abth., p. 250. 
t Ueber xerosis conjunctivcB, Inaugural thesis, Breslau, 1868. 



KERATOMALACIA. 23 



Simultaneous concurrence of general marasmus. Thus we have 
a well defined morbid picture in the symptom-complex : maras- 
mus, xerosis of the conjunctiva and suppuration of the cornea. 
If the children do not succumb in consequence of their 
marasmus, which is most frequently the case, serious impairment 
of the visual faculty or complete blindness remains. The disease 
IS most frequently met with amongst us in children who are 
affected with marasmus as a consequence of hereditary syphilis ; 
but on the whole this is a rare occurrence.* It is met with more 
frequently in Russia and Brazil. In Russia it is especially 
prevalent after the great fasts, and destroys or makes blind 
many children.f In Brazil the ill-fed children of the negro 
slaves are its chief victims.^ — In the treatment the chief thing 
to attend to is the improvement of the nutriment; the local 
employment of warm fomentations seems to do most good 
(GOUVEA). 

Many other maladies of childhood, such as the exanthemata, 
typhus, meningitis, whooping-cough,§ &c., may be accompanied by 
eye diseases. I shall return to this subject hereafter (in Part IV). 



♦ Among his 1000 cases of blindness, Cohn gives eight cases of kerato- 
malacia. 

t Thalberg Archivf. Augenheilkunde^ B. XII., p. 320. 

X GouvEA, V. Graefe's Archiv /. Ophth, Bd. XXIX., Abth. i, p. 167. 
GouvEA and Leber (v. Graefe's Archiv^ Bd. XXIX. Abth. 3, p. 225) give 
the literature of this subject. 

§ Landesberg (Med, and Surg. Reporter^ Vol. XLIIL, Sep., 1880) re- 
ports four cases of eye affections after whooping cough, two of neuritis optica 
(in one case with V = 4 J, in the other with V = ^\j), one of exophthalmus, 
one of luxatio lentis. 



Part III. 

Eye Diseases incident to the Educational 

Period. 

The eye diseases which are most frequently acquired in this 
period of life are myopia and trachoma. The latter, which is 
endemic in the orphanages and schools of many countries, shall 
be considered later on ; this chapter shall be devoted exclusively 
to myopia. 

Chapter I. Causes of Myopia. 

§ 7. Myopia may be congenital or acquired — we not un- 
frequently find persons coming to the dispensary for myopia, 
belonging to the country-folk, who may perhaps have never 
learnt to read, and most assuredly have never strained their eyes 
by looking closely. They have generally a high degree of 
myopia, and allege that they have been short-sighted as long as 
they can remember. These are cases of congenital myopia; 
they have nothing to do with the kind of occupation of their 
subjects, and occur in pretty much the same proportion in all 
classes of society. This is well shown in TSCHERNING'S essay.* 
He examined men belonging to all classes of society as they 
presented themselves for the military conscription. He divided 

* V. Graefe's Archiv^ Bd. XXIX., Abth. i, p. 201. 



^^H CAUSES OF MYOPIA. 25 

them into six classes, according as their occupation demanded a 
greater or less exertion of the eyes. He found that the higher 
degrees of myopia, above 9 D., were pretty equally distributed 
through all six classes. When he placed together the three 
higher classes on one side, and the three lower classes on the 
other, he found that the former had only 0.56° /g, while the latter 
had o.73°/g of this congenital higher degree of myopia.* 

§ 8. Whilst congenital myopia is rather rare, i3i:^«^y^i//«j'(7^/(j' 
is much more frequent. Consequently it merits our special atten- 
tion, and all the more because we can to a certain extent prevent 
it, which naturally we cannot do in the case of congenital myopia. 

Acquired myopia is the result of several factors, among which 
prolonged work requiring close vision takes the first place. The 
influence it has on the development of myopia is shown by the 
following circumstances; — i. That myopia is seldom found 
among new-born infants; 3. nor among uncivilized people; 3. 
that among civilised people myopia is found in exact propor- 
tion to the calls on the eyes for exertion. 

The first investigations instituted with respect to the refrac- 
tion of new-born infants were made by jAEGER.f He found that 

' SORMANI (Dati statislici relativi alia distribuzione della miopia e della 
ceciti in Italia. Ann. di Ollalm., Vol. X., p. 546, 1881) found the greatest 
number of myopes in Italy among the inhabitants of the southern provinces 
and the sea-coast. Among more than 1,000,000 recruits from these regions, 
2.8°/„ were short-sighted, with a myopia above 6.5 D ; and yet the occupa- 
tions of this population were not of a character to make a great demand on 
the eyes ; 70°/„ of the recruits could not even read ; therefore these statistics 
had to do with myopia independent of the occupation, and most probably 

^^congenital. 

^^^L t Einstellungen des dioptrischen Apparales, p. 10. 



26 MYOPIA IN INFANTS. 

among lOO children of from 9 to i6 days old 78 had My., 17 H., 
and 5 E. These investigations, which for a long time were 
considered conclusive, have lately been repeated and refuted. 
HORSTMANN* found among 79 new-bom children 9 myopes; 
ELYf among 100 only 11; KoenigsteinJ found among 600, 
SCHLEICH§ among 300 new-born children not one myopicH 
With respect to the observations of HORSTMANN and ELY on 
the short-sight of children, their myopia is probably owing to 
the too great refractive power of the lens, and most of their eyes 
probably became emmetropic as they grew older. This seems 
to be proved by the circumstance that COHN found only 14°/^ My. 
among the children of village schools.ir — Children are not, as a 
rule, born with myopic eyes, nor do they become myopic later on 
if they do not need to strain their eyes by looking closely. 
Among uncivilised people, therefore, myopia is as rare as among 
new-born children. — Among civilized people the number of 
myopes is in direct proportion to the amount of work requiring 
close vision, demanded by the occupation of each individual. It 

* Bericht iiber die] Heidelberger Ophthalmologen-Versammlung^ 1879, 
p. 241. 

t Knapp's Archivf. Augenheilkunde^ Bd. IX., p. 431. 

% Wiener medicinische Jahrbiicher^ 1881, p. 47. 

§ Mittheilungen aus der ophth, Klinik in Tubingen^ Bd. II., p. 44. 

II Since then (at the International Medical Congress at Copenhagen, 
1884) further investigations have been recorded upon the eyes of new-bom 
children by Bjerrum and Lowegren, which confirm the above results. 

If Die Hygiene des Auges in den Schulen, 1883, p. 47. Most of the fol- 
lowing data are taken from this admirable work. As it contains a full resunti 
of the literature of the subject, I have given but few references to other 
works in what follows. 



INFLUENCE OF OCCUPATION. 27 



has long been noticed that there are many short-sighted persons 
in the learned professions. This observation gave the impulse 
to the works of COHN and his followers. 

The best opportunity for observing the influence of occupa- 
tion is afforded by investigations which have to do with a large 
number of persons irrespective of their position in life, as, for 
example, those made on persons who present themselves for 
military service. Seggel* and TsCHERNINGf have recorded in- 
vestigations of this kind. 

Seggel examined 1,600 soldiers of the Munich garrison. 
According as their occupation required less or more close work^ 
he divided them into 5 classes : The first included country folks ; 
the second those employed in open-air avocations in towns, such 
as day-labourers, &c. ; the third, handicraftsmen and artisans ; the 
fourth, tradesmen, merchants, writers, printers, &c.; the fifth, those 
who offered themselves as one-year volunteers, these were chiefly 
students. Myopia in these classes rising from the lowest to the 

highest was : 27,, 47o> 97o, 44Vo, and s87o. 

Tscherning's investigations included 7,523 persons liable to 
military service, who were similarly arranged in 6 classes. In 
those classes myopia was found to increase in the following ratio : 

27o, S7o, i27o, i37o, i67o,and 327o. 

It is evident from these figures that the chief cause of ac- 
quired myopia lies in the requirements of the occupation. 
Myopia is thus seen to be the melancholy privilege of the learned 



♦ Bayer, drztl, Intellegenzblatt^ 1878, p. 33. 

t V. Graefe's Archiv^ Bd. XXIX., Abth. i, p. 201. 



28 



MYOPIA IN SCHOOLS. 



professions. Next in order are those occupations which make 
especial demands on the eyes. The latter will be considered 
later on ; at present, we shall occupy ourselves exclusively with 
the influence of study on the eyes. 

§ 9. SliorUsightedness in Schools. 

To COHN belongs the great merit of having first instituted 
extensive investigations relative to the eyes in schools in a 
strictly scientific manner. His example has given rise to a great 
number of works bearing on this subject. From all these inves- 
tigations it appears that, i, the number of myopes is greater the 
higher the school is ; 2, that in each school the number of myopes 
increases from the lower school classes to the higher ; and 3, 
that with the number of myopes the average degree of myopia 
increases. 

I. The number of myopes is greater the higher the school is. 

This is best illustrated by the table which COHN gives relating 
to more than 1,060 children he examined. In order to include 
the schools of highest education (universities) in this table, I add 
108 medical students also examined by Cohn.* 





Percentage of 
Myopes. 




Average degree 
of Myopia, 


Village Schools 


1.4 


• . 


"/24-4 


Elementary Schools 


6,J 


• . < 


I22.7 


Higher Girls' Schools 


... 7.7 


.. 1 


• """" 


Middle Schools 


... 10.3 


• • < 


x/ 
/2Z.9 


Technical Schools... 


... 19.7 


• .< 


/i9'6 


Gymnasia 


... 26*2 


• • < 


Vx8.7 


University 


... 59 


••< 


1/ 

• / 12,2 



♦ The eyes of medical students, Wiener medic. JaJirhucher^ 1881 



PROGRESSIVE INCREASE OF MYOPIA IN CLASSES. 29 



This table does not deal with such large numbers as I might 
have obtained, had I taken the average of all the data given in 
Corn's work. But it has the advantage of being more uniform, 
the observations were made by the same observer in the same 
manner, and relate to one country. The picture they present to 
us of the progressive increase of myopia is sufficiently striking. 
And yet the numbers of the table are not equal to those given 
by many other authors. Thus COHN has in his own investiga- 
tions left out all myopias under 1/36 (i D)* In the collection 
given by COHN, we find no fewer than 5 gymnasia in which the 
myopes were more than 50°/^. Among the divinity students of 
Tubingen GAERTNERf found 78°/^, of myopes. 

2. In each school tAe number of myopes increases from class to 
class upwards. 

In illustration of this assertion, I may adduce the figures 
ascertained by COHN in the gymnasia. The number of the 
short-sighted in the several classes rising from the lowest to the 
highest was: 15.5%, 18.2%, 23.7%, 317,, 4i.37o, SS-SVo- The 
diagram on next page is also taken from COHN. It represents 
the increase of myopia from the lowest to the highest class in 
24 gymnasia and technical schools investigated by him. The 
curve shows higher values than the figures just cited, because 
in it the lowest degrees of myopia are admitted. 

3. Not only the number of myopes, but the average degree of 



* The investigations relating to medical students are an exception to this. 
t Berlin a;/// Rembold, Untersuchungen iiberden Einfluss des Schreibens, 
Stuttgart, 1883, p. 46. 



30 



PERCENTAGES OF MYOPES IN SCHOOL CLASSES. 



myopia also ^ureases. This is seen by the figures given in the 
table at p. 19. 



PERCENTAGE OF MYOPES IN 




Fig. I. 

From the facts adduced the following conclusions may be 
drawn : i. That during the period of study a large number 
of emmetropic and hypermetropic children become myopic ; 
2, that in myopes the degree of myopia constantly increases. 
These two facts are moreover directly proved by investigations 
made on the same school children at various times. 



STUDY THE CHIEF CAUSE OF MYOPIA. 3 1 

Investigations of this sort were also first undertaken by COHN.* 
He found that more than one half of myopes underwent an in- 
crease of their myopia ; in the 18 months that elapsed between the 
two investigations the myopia had increased from an average of 
V20.6 to an average of 7i4.6- That implies an increase of 
refraction of V50 (0.75 D) in i^ year, or of ^/^j (0.5 D) in 
one year. — ^Among medical students COHN found not fewer 
than 37°/^, whose myopia exceeded '/q (4 D.). We must take 
for granted that in many of these cases the myopia continues to 
increase after the studies are over. If this take place only to 
the extent of V75 P^r annum, that will in the end cause very 
high degrees of myopia. We may imagine what kind of future 
awaits many of these young people as regards their eyes. 

Of all the occupations requiring close vision, study is the 
most dangerous for the production of short-sight. This is not 
the place to describe the mode in which straining the eyes tends 
to produce myopia, that is to say, elongation of the eye ball. 
Thus much only we may say here, that in general the extreme 
and long continued accommodation and convergency are the 
hurtful factors. They exert their baneful influence all the more 
certainly seeing that the majority of students practise them in a 
perniciously high degree. The excellent investigations made 
by Berlin in conjunction with Rembold, show that almost all 
school children hold their books, &c., much closer to their eyes 



♦ In his Hygiene des Auges^ at pp, 65-67, CoHN gives the literature deal- 
ing with this subject; since then Reich (v. Graefe's Archiv^ XXIX. 
2, 203) must be added to the list. 



32 CAUSES OF MYOPIA. 



than IS necessary : in one class of six year old girls the average 
distance of the eyes from the pen's point was only 4j^ inches * 
§ 10. The question arises, how does it happen that all 
individuals who have to strain their eyes to a certain degree do 
not become short-sighted, but only a certain number of them ? 
We need not at present consider those cases where single individ- 
uals work under specially unfavourable conditions (bad illumina- 
tion of their homes, straining of the eyes in order to earn 
their bread, &c.). As regards the rest, the reason must be 
that these are circumstances purely personal to themselves 
which favour the development of myopia. These circumstances 
can be none other than certain anatomical peculiarities of the 
eyes and their appendages, of which, however, we yet know 
extremely little. Those factors that predispose to myopia are : 

1. Defective acuteness of vision^ which compels its subject to 
bring objects closer to his eye. To this belong congenital 
defects of the eye, such as albinism, astigmatism, congenital am- 
blyopia, &c. ; also acquired defects, such as opaque spots on the 
cornea. 

2. Disturbances of the equilibrium among the muscles of 
the eye. 

3. Heridity, The influence of heridity is shown in this, 
that the children of short-sighted parents though they may not 
be born short-sighted, nevertheless possess a peculiar tendency to 
become short-sighted under certain conditions. 

I may take this opportunity to say something about short- 



* L. C, p. 32. 



MYOPIA IN THE TWO SEXES. 



33 



sightedness in the female sex. It might be supposed that women 
have the advantage over men in this respect. This advantage 
is partly only apparent, for many short-sighted women object to 
wear spectacles. Partly, however, — in former times at least — 
their education made slighter demands on their eyes and hence 
rendered them less liable to become myopic. Nowadays this 
appears to be no longer the case. 

Recent investigations have shown that as regards short sight, 
there is no great difference between the two sexes. In the fol- 
lowing table I have put together the investigations which have 
been collected by one and the same observer in the same place 
relating to a boy's school and a girl's school of the same rank. 
Such investigations best permit a comparison. No doubt there 
may be differences in the illumination of the schools or in the 
programme of instruction of schools otherwise similarly con- 
ducted, for which it is difficult to make allowance. 







Percentage of 


Myopia in 








Boys. 


Girls. 


Netoliczka 


Graz, 1 88 1 


Village School 


4 


8 


n 


M 


Town School 


10 


13 


Pflueger 


Lucern, 1876 


Lower School 


f 

5 


8 


NiCATI 


Marseilles, 1879 


Primary School 


8 


7 


» 


» 


Jewish School 


1 

15 


10 


Florschuetz Coburg, 1880 


Town School 


12 


14 


» 


» 


» 


4 


7 


Just 


Zittau, 1879 


» 


15 


14 


Reich 


Tiflis, 1878 


Gymnasium 


37 


25 



34 INFLUENCE OF RACE ON MYOPIA. 

4. Race. It is a fact that the frequency of myopia is often dif- 
ferent among different nations. But the difference depends in 
great measure on the different degree of culture. As has 
already been remarked, myopia is almost unknown among un* 
civilized people. In order to ascertain if a given race possess a 
special disposition to short-sight, a comparison must be made 
among civilised nations, and this must be done with the greatest 
care. We have seen how greatly short-sight varies according to 
the occupation, and even according to the particular years of 
study. But should we even compare schools of similar charac- 
ter, cg.y a Russian or French with a German gymnasium, we 
should not be able to draw any satisfactory conclusions therefrom. 
There always remain differences in the illumination of the 
school-rooms, in the construction of the school-forms, in the 
programme of instruction, in the mode of living of the 
scholars, &c., which have the greatest influence on the number of 
the myopes. Erismann has shown how much boarding in the 
school is to blame for the occurrence of short-sight The day- 
scholars have 354°/o, the boarders 42. 1°/,, of myopes. DOR 
found in the Lyons Lyceum among the day-scholars 18®/^, and 
among the boarders 33°/^ of myopes. Thus we can only make 
use, for the purposes of comparison, of the few investigations 
referring to mixed schools, in which scholars of different nations 
are educated under identical external conditions. These inves- 
tigations are subjoined : — 



IS MYOPIA A PUBLIC DANGER? 



35 



LORING & 

Derby 

COLLARD 

Pflueger 

NiCATI 



99 

Reich 



New York, 

1876 
Utrecht, 

1881 
Switzerland, 

1875 
Marseilles, 

1879 



Tiflis 



1878 



University 

Teachers 

Boys' School 

Girls* School 
Boys' Gymnasium 
Girls* Gymnasium 
Town School 
Teachers' 
Institution 



Per cent, of Myopia. 



Germans, 24 

Germans, 40 

Germans, 24 

Jews, 15 

Jews, 10 
Russians, 30 

n 2 
8 



>» 



Americans, 20 

Dutch, 27 

French, 14 

Christians 

(French) 8 
Christians, 7 
Armenians 38 

y, 24 

14 



if 



>» 



25 



Irish, 



14 



Georgians 45 
21 

14 



>} 

>* 



»» 



10 



According to this table, the greatest proportion of short- 
sighted were found among the Germans and Jews, but the 
observations are altogether too few to admit of definite con- 
conclusions being arrived at. 

§ II. Having shown the frequency of myopia in certain 
classes of the community, we must enquire if it is an affection 
which seriously threatens the faculty of vision? Are we 
justified in regarding short-sight as a public danger, which 
must be guarded against by all the means in our power ? 

In the majority of myopes, the myopia remains stationary 
at a low degree. It is not attended with any danger to the 
sight, and as a rule does not prevent the following of 
any occupation. On the other hand, in a certain minority 
the short sight attains such a height that, in the first place, it 
makes its subject incapable of following certain occupations, 
and, in the second place, it seriously threatens to destroy the 
sight in the course of time. The cases of absolute blindness as 
a consequence of short-sight are no doubt rare in comparison 



36 PROPHYLAXIS OF MYOPIA. 

with the large number of myopes. According to MAGNUS chorioi- 
ditis e myopia furnishes 0.94°/o of the blind. To these may be 
added a portion of the cases of detachment of the retina, which 
altogether constitute 5.68°/^ of blind persons. On the other 
hand, much more numerous are the cases in which myopes, as 
they grow older become not indeed totally blind, but so weak- 
sighted as to be incapable of earning their subsistence. COHN 
in his statistics of blindness, includes all eyes which cannot be 
employed in work. In these statistics, detachment of the retina 
as a consequence of myopia is given at 4.6°/^, retinitis centralis e 
myopia 6.3°/^, so that myopia is the cause of loVo ^^ ^^^ cases 
of blindness of one eye. 

It may also be asserted that very short-sighted persons are 
proportionally subject to a greater number of injuries than 
others. 

Chapter 11. Prophylaxis of Myopia. 

How then can we guard against this public calamity, 
myopia ? 

The general extension of public education, its increase in pro- 
fundity and extent is one of the most excellent gains of modern 
times. We must not diminish this gain ; we must not oppose 
any of the essential requirements of education. But we must 
seek to watch over it, so that its injurious effects on the health of 
the scholars must be reduced to a minimum. For this end a 
number of measures are necessary, some of a general sort ap- 
plicable to all schools and scholars, some of a special sort for the 
several stages of education. 



LIGHTING OF SCHOOL-ROOMS. 37 

I. GENERAL MEASURES. 
(a) Measures Relating to the School-room. 

§ 12. I. Illumination, In his first investigations in 1865 
COHN paid particular attention to this factor. Twenty elemen- 
tary schools examined by him, in which the requirements of the 
education were pretty much alike and therefore admitting of a 
comparison, shewed a variation in the number of myopes of from 
1.8**/^, to 15°/^, dependent on the illumination of the school-rooms. 
The new schools situated in broad streets, had from 1.8 to 6.6^ j^^ of 
myopes. Florschuetz in 1874, found 2i°/„ of myopes in the 
Coburg schools. In 1877 after a number of new schools had 
been built, the number of myopes had diminished to i.s7o> ^^ 
that the importance of good illumination is indubitable. 

What is the quantity of light needed for a school-room ? Bad 
illumination is hurtful, because it compels the writing or book to 
be held too close and thus necessitates excessive accommodation 
and convergence of the eyes. The illumination is sufficient when 
it allows even smaller print, e,g, Snellen 0.5 to be read at a 
convenient distance, as for instance 12 inches. — There are 
various ways of judging of the illumination of a school-room. 

The first method is to ascertain how large a portion 
of the sky can be seen from every place in the school- 
room. As regards the school-room, it is not merely the 
general illumination, but the illumination of every single 
place in it that has to be examined ; the worst place must 
receive a sufficiency of light. This method was proposed by 
J AVAL, and also by a commission appointed by the French 



38 MEASUREMENT OF THE ILLUMINATION. 



government in 1881. This Commission laid down as the 
minimum of illumination, that an eye at the height of the school 
desk should be able to see the sky in a vertical extent of at 
least 12 inches, reckoned from the upper border of the 
window. Against this I may allege that the illumination of 
a place in the school-room does not depend only on the portion 
of visible sky, but also on the reflection of the walls, &c. It is 
difficult to estimate these factors for every special case, so that it 
is better to measure directly the quantity of light secured by 
each place. 

A second method takes the acutcness of vision as the measure 
of the illumination. Various propositions have been made in 
this sense, HOFFMANN requires that Snellen 6 should be read 
at 20 feet. By this method we certainly ascertain something 
as regards the illumination of the Snellen table hung up on the 
wall, but nothing respecting the place from which it is read. 
Laqueur'S plan is better, which requires that diamond type 
should be easily legible at a distance of 20 inches. 
Landolt's photometer goes on the same principle. A small 
card has a group of black spots on a white ground, the distance 
between the spots is ^/sth of an inch. In order to be able to 
employ the card for any particular school -desk, it is connected 
with a mirror in such a manner that the mirror throws the rays 
proceeding from the points farther in a horizontal direction. 
With the best illumination, Landolt distinguishes the points at 
16 feet, in a well-lighted room at 10 feet. Hence he denominates 
the illumination of this room as s/gths of the maximum-illumina- 
tion, for he reckons from the (disputable) proposition that the 
acuteness of vision is in direct proportion to the illumination. 



WEBER'S PHOTOMETER. 39 



These methods have this fault, that their standard of 
measurement, to wit, the acuteness of human vision is not a 
fixed standard. There are persons who have a double acute^ 
ness of vision and more ; they will be capable of reading Sn. 6 
at 20 feet in bad illumination. To others who have exactly V. ^U 
Sn. 6 may easily become illegible. Others, on account of 
short-sight, astigmatism, &c., cannot have such a test applied to 
them. When an oculist investigates the lighting of a room, he 
may make allowances for these circumstances in the use of 
his own eyes. But it were desirable to have a method which 
should give reliable results also in the hands of others, e.£.y 
teachers, architects, &c. For this reason the attempt has been 
made to make use of the methods of photometry. 

P^ pJiotometric methods give, not an absolute, but a relative 
measurement of the intensity of light, by the comparison with 
one another of two sources of light. On this principle 
Bertin-Sans has constructed a photometer intended for 
school-rooms.* With this apparatus I have instituted a series 
of experiments, which, however, have not yielded very satis- 
factory results. Quite recently COHNf made use of a photo- 
meter constructed by L. Weber, which fulfils all requirements. 
Unfortunately, the high price of the apparatus (;^I5) militates 
against its general use ; therefore it would be very desirable to 
have a simple cheap photometer which could be easily used 
by everyone, and yet give sufficiently accurate results. 



* Afmaks-^Hygilney Tome VII., pp. 46 and 127. 
t Deutsche med, Wochenschrifty No. 38, 1884. 



POSITION OF SCHOOL HOUSE. 



In order to fulfil the necessary requirements relative to 
illumination, the following points should be attended to in the 
construction of a school. 







































r 


1 









Fig. 4. 

§ 13. I. Position of the school house. Before all things 
it is desirable to ascertain from what point of the compass we 
can obtain the illumination.* 



• In the cuts, O stands for East. 



POSITION OF SCHOOL HOUSE. 4I 

Almost all are agreed that the windows should look towards the 
east and south east. A few (LANG and Reclam) prefer the 
aspect towards the north in order to avoid the direct incidence 
of the sunlight; but the direct sunlight can be warded off 
by various contrivances. Rooms on the sunny side are more 
easily warmed in winter, they are much the most cheerful and 
wholesome. 

Hence the best aspect of the windows will be that towards 
the east and the approximate north-east and south-east. A 
westerly aspect is only suitable for school-rooms in which no 
afternoon instruction is given. A due north aspect is to be 
avoided, because it is so dark and sunless in winter. Nor does 
a due south aspect seem to me advisable, because in summer it 
gets too much heat and direct sunlight. — Hence a school-room 
is well placed if its axis runs nearly north and south. The 
teacher is placed on the south side, the windows on the west 
side (fig. 2). The direction of the axis towards north-east (fig. 3), 
or south-west (fig. 4), also permits the windows to have a good 
aspect, namely, towards south-east or north-west. 

It is impossible to say anything about the position of the 
whole school building, because the form of the ground plan and 
therewith the arrangement of the space, may vary extremely. 
In general we can get a greater number of favourably con- 
structed rooms, if the school building have its corners rather than 
its fagades directed towards the principal points of the compass 
(Hesse commission, JAVAL) ; by adopting this plan, we shall 
avoid the very objectionable due north fagade. 

It is evident that climate constitutes an important factor in de- 



42 SURROUNDINGS OF SCHOOL HOUSE. 



termining the site of a school. The principles just laid down are 
applicable to a temperate climate like that of Germany or of the 
middle and north of France. We should have to act in southern 
countries, where a pure north aspect may be the best for the 
school-room, otherwise than in northern countries, as for example 
England, where the prevalence of a cloudy sky and the moisture 
of the atmosphere would call for a due south aspect. Some- 
times also local conditions, as for instance, a high mountain 
range, some special prevalent direction of the wind, &c., require 
special consideration. 

The circumstances above mentioned to be attended to in re- 
gard to the position of the school-room are mostly inapplicable 
when the illumination is affected by means of a skylight In 
that case it is of no importance, so far at least as the lighting is 
concerned, how near the surrounding buildings are. But in the 
case of lighting from the side, this point requires particular atten- 
tion, which seems not always to be bestowed on it. COHN very 
properly disapproves of the situation of the Magdalen Gym- 
nasium of Breslau, which has been built quite close to a high 
church that takes away the light from many of the school- 
rooms. — In order to ascertain at what distance the neigh- 
bouring houses ought to be, we must look to the school-rooms 
on the ground floor. We ought to be able to see a bit of 
sky through the window from the school seats farthest from the 
window. As a simple calculation shows, this will only be the case 
when the opposite houses are distant from the school house at 
least twice as far as their height (J-AVAL). Only verj" low build- 
ings, under 33 feet in height, may stand somewhat nearer than 



POSITION OF SCHOOL-ROOM WINDOWS. 43 

twice their distance. ZWERZ says that the height of the houses 
opposite measured from the window-sill of the school-room ought 
not to exceed from 20 to 25.® This corresponds pretty nearly 
with what is stated above as to the desirable relative height and 
distance of buildings opposite the school. 

In the building of a new school-house a sufficient plot of 
land should be purchased or kept unbuilt on by agreement, so 
that the distance between the school and surrounding houses 
should be at least double the height of the latter. A part of this 
land may be appropriately laid out as a garden. If, for any 
reason, it should be impossible to keep such an amount of 
land unoccupied, then the ground floor on the sides of the 
building where the light is obstructed by houses opposite should 
not be used as schoolrooms. 

In such cases, the precedent of the school of St. Denis might be 
followed by constructing a large courtyard on which the windows 
of the school-rooms look. The dimensions of the courtyard in 
relation to the height of the building, should of course, be the 
same as those above enumerated. 

§ 14. — 2. Position of the windows, — It is important to attend 
to the position and dimensions of the windows. As regards the 
position of the windows, there is no doubt that 2i skylight affords, 
relatively, the greatest quantity of light. It is only necessary to 
visit artists' studios, factories and the like, illuminated in this 
way, to convince ourselves of the truth of this. The disadvan- 
tages alleged against lighting by means of glass roofs are snow 
in winter and the sun in summer. The first is easily removed. 
As regards the last, I admit that in warmer countries, such as 



44 LIGHTING FROM THE LEFT SIDE. 

Italy, schoolrooms with glass roofs are intolerably hot in 
summer, and therefore not advisable. But in cooler countries 
this will not be the case. The direct sun's rays must, of course, 
be warded off (by means of blinds). If this is attended to, then 
illumination by means of light from above is no doubt the best 
and I cannot understand why the French regulation of 1880 
should say : — " Lklairage par un plafond vitr^est inter ditr Un- 
fortunately, illumination by light from above can only be carried 
out to a limited extent, owing to architectural difficulties. 

When the light comes from the side it must be exclusively 
or chiefly from the left side. The former, to wit, illumination 
from one side, suffices for small and medium-sized school-rooms, 
and in such it ought unhesitatingly to be preferred. Larger 
school-rooms can only be exclusively lighted from the left when 
they are sufficiently lofty, so that the daylight falls upon the 
seats at the extreme right in a not too sloping angle.* It is not, 
therefore, enough that there should merely be a certain relation 
between window surface and floor surface, but there must also 
be a proper relation of the height of the upper border of the win- 
dow to the depth of the room. 

JAVAL insists that in illumination from one side the distance 
of the upper border of the window from the floor should be equal 
to the depth of the room. Trelat is satisfied if the height of 
the upper border of the window is 0.6 the breadth of the room, 
plus the thickness of the wall. On the other hand, the French 



* In a sloping incidence of light the illumination of a surface stands in 
direct relation to the cosine of the angle of incidence. 



LIGHTING FROM BOTH SIDES. 45 

law of 1880 requires that the windows should be two thirds of 

the depth of the room. This should be the minimum, below 
which we ought on no account to go. — It is sometimes necessary 
to provide school-rooms for a large number of scholars, therefore 
the rooms must be larger. The length of the room should not 
overstep a certain limit, in order, on the one hand, that the 
scholars should still be able to see the boards, and on the other 
hand, that the voice of the teacher should be audible on the 
farthest forms. Hence, the rooms should be of considerable 
breadth. But here the limit of the exclusively left-sided illumi- 
nation is soon reached, because, on account of architectural 
considerations, the height of the rooms cannot be increased as 
much as might be desired. 

Great as are the advantages of lighting from one 
side, still, it is not right to proscribe absolutely lighting 
from two sideSy as has occasionally been done. Illumination from 
two sides is certainly better than insufficient illumination ; it is, 
moreover, a good illumination, if reasonably carried out* The 
second row of windows may be set at the back or right side of 
the scholars (never in front of them). In everj-** case the windows 
must be so arranged that the light from the left greatly preponde- 
rates. The superficies of the left-side windows should constitute 
at least two-thirds of the whole window superficies, as was the 
case, for instance, in Ferrand'S school-house in the Paris In- 
ternational Exhibition of 1878. 



* I may mention that windows opposite one another facilitate adequate 
ventilation. 



46 NUMBER AND HEIGHT OF WINDOWS. 

If the number of windows on both the long sides of the room 
be equal we shall best fulfil the above requirement, by con- 
structing the windows on the right side so that they do not come 
down so low. In this way we shall most certainly prevent the 
scholars who sit farthest right from having the shadow of their 
pen on their left side. 

Attention should be given to the position of the room in 
relation to the points of the compass, for it will aid us in securing 
a good distribution of the light. Let us suppose the room to be 
so placed that its two long sides look south-east and south-west 
The teacher should be placed at the narrow south side of the room, 
and twice as many windows should be made on the south-west 
side as on the north-west side. As — in the forenoon hours at 
least — the light coming from the south-east is much greater 
than what comes from the north-west, we shall at all events be 
able to secure a good distribution of the light. 

How far should the windows extend up and down ? The 
higher the upper boundary of the window is, the better ; hence, 
if possible it should reach up to the ceiling. On the other hand 
the lower boundary of the wifidow requires a certain limitation. 
If the latter comes down too far, part of the light from below 
falls in the scholar's eyes and dazzles him. Hence the window 
sill should be at about the level of the heads of the school 
children when they are seated. Forty inches high appears to me 
to be quite sufficient (Strasburg Report). A higher elevation of 
window sill needlessly diminishes the superficies of the window. 
The French regulation orders 4 feet.t Trelat advises 4 feet, 

t R^gletnent pour la construction^ &*c, Arretd minis teriel du ly Juifiy 
1880. 



DIMENSIONS OF WINDOWS. 47 



4 inches, the Brussels commission 5 feet, 2 inches. In this last 
case the school-room has a prison-like appearance. — Should it 
be feared that the attention of the scholars would be distracted 
the lowest panes of the window may be made of ground glass. — 
I have mentioned above that other considerations come into 
operation with regard to windows on the right of the scholars, 
which render it desirable that those windows should not come 
so far down. 

Irrespective of their lower boundary, the dimensions of 
the windows may be too small, but cannot be too large. The 
only thing to be done is to fix the lowest Wmit for the dimen- 
sions of the windows in proportion to tJie size of the room. In 
calculating the superficial dimensions of windows, the window 
curtains and the cross bar must be deducted. COHN in his 
work describes a number of model schools exhibited at the Paris 
and Vienna International Exhibitions. In them the proportion 
of window superficies to floor superficies, varies from i to 8.6 
(Prussian school-room at the Vienna Exhibition) to i to i 
(Ferrand'S school-house at the Paris Exhibition of 1878). 

The actual illumination proportions in existing schools fall 
very short of those of these model schools. Blasius examined all 
the schools of the Duchy of Brunswick, which possess in all 807 
classes. Of these 3.1 °/^ had the proportion of window to floor 
superficies of i to 4 or an even more favourable proportion ; 
22.7 **/o had the proportion of from i to 4 to i to 7. The former 
of these classes were excellently, the latter sufficiently lighted. 
In the remaining 74 °/q there was i square yard of glass to 
more than 7 square yards of floor surface, so that fths of all 
the school-rooms were insufficiently lighted. 



48 COLOUR OF SCHOOL-ROOM WALLS. 

What should be considered the minimum of good illumina- 
tion ? COHN requires a proportion of i to $ as the minimum ; 
Erismann I to 4.5 ; the Brussels Commission i to 6. Many 
of the established commissions, as also many government ordi- 
nances on the subject lay down no fixed proportion between 
window and floor superficies, but content themselves with pre- 
scribing the height and width of the windows. I have examined 
the newly built grand middle and technical school of Liege, in 
which, following the Belgian regulations, in most of the rooms 
the proportion of i to 6 is maintained. In these rooms the 
lighting of the seats farthest from the windows is very good on 
bright days, but on dull days insufficient. Therefore I feel 
compelled to agree with COHN in adopting a minimum of i to 
5. — ^With an equal window superficies, many windows are prefer- 
able to few, for in the former case there is no obscuration of 
some seats by broad wall spaces between the windows. 

The colour and form of the walls affect the illumination. 
The walls must be bright in order to reflect the light properly, 
but not so bright as to dazzle the scholars. Hence Corn's sug- 
gestion to employ a bright gray colour should command general 
assent. 

Direct sunlight should be kept from falling on the school 
forms. This object may be obtained by the use of ground glass 
window panes, curtains of various stuffs and blinds of different 
kinds. Ground glass window panes are sometimes very dazzling. 
I consider simple gray linen blinds the best. As regards the 
fixing of these, COHN prefers the mode adopted in the American 
model school-house of the Vienna Exhibition; in this the 
blinds were placed in half the height of the window, so that the 



ARTIFICIAL LIGHTING OF SCHOOL-ROOMS. 49 



upper half of the window or the lower half or both together 
can be shaded. 

§ 1 5. Artificial illumination is required for evening instruction^ 
as also in winter for the first hour or even the first two hours. 
In primary schools in which the hours of instruction are few, 
the bright time of the day may be chosen for lessons. Artificial 
illumination is chiefly applicable to middle and upper schools. 
As these are almost exclusively found in towns provided with 
gas, the lighting of schools is, as a rule, effected by gas. Ac- 
cording to Corn and Varrentrapp, there should be one 
burner for every four scholars (with two-seated desks). All 
burners should be provided with glass chimneys and shades. 
In front of the school-desk there should also be one, and still 
better, two lamps (one on each side). A tin reflector throws the 
light of the lamp on the desk, and at the same time shades it 
from the scholars' eyes. When gas cannot be had, petroleum is 
preferable to oil. 

For larger schools with evening instruction, especially for 
drawing lessons, electric lighting is advisable. The first employ- 
ment of this, as far as I am aware, was made in the middle and 
technical schools of Liege, which were opened in October, 1883. 
Three rooms for drawing classes are lighted by electricity, each 
room 13 '/3 yards wide and twice that length was lighted by 
two electric sunlights. These were fixed to the lower end of 
iron rods which hung half way down into the room. Underneath 
each sunlight there is a concave mirror, one side of which shades 
the light from view, while the other throws the light on to the 
white-washed ceiling. From this it is reflected throughout the 
4 



50 WORKING DISTANCE. 

room. Thus the light comes from above and falls in pretty 
equal degree upon all the desks, whilst the sources of the light 
themselves are invisible. The light is quite sufficient, but not 
at all dazzling.* 

§ 1 6. — 2. The seats and desks, — One of the chief causes of 
school-myopia is, that by having the objects too close to them, the 
scholars strain their eyes more than is required by the work 
they are engaged on. 

The working distance has a fixed relation to the size of the 
body (Berlin) ; children, on account of the shortness of their 
arms must have their writing nearer to them than youths or 
adults. These differences incident to age, correspond to the 
greater power of accommodation in childhood, which diminishes 
as age increases. But within these limits attaching to the size 
of the body the working distance varies greatly. It is the 
product of a number of factors, to wit : i. Acuteness of vision 
and refraction. 2. Illumination. 3. Size of the object. 4, 
Method of writing. 5. Construction of the school-seats and 
school-desks. 6. Customaiy position. With the exception of 
the first (acuteness of vision and refraction) all these factors are 
under our control. If they are regulated in accordance with the 
requirements of hygiene, there will be few children who — on 
account of faulty refraction or defective acuteness of vision — 
will be obliged to have the objects close to their eye. We have 
first to consider the subject of seats and desks. 

The scholar sits in a proper manner if the upper part of his 



* See also § 63, Artificial illumination. 



CONSTRUCTION OF SCHOOL SEATS. 5 1 

body is straight, so that pelvis and shoulders are parallel to the 
border of the desk, and the head is upright or slightly bent 
forwards. The feet should rest upon the floor, the back sup- 
ported by a sacral rest. When writing, the forearms, but not the 
elbows also, should rest on the desk. This posture is not less 
important for diminishing curvatures of the spine than for pre- 
venting myopia. An indispensable requisite for this is a pro- 
perly constructed seat. There is at present a great number of 
models of good school-seats, which I cannot here pause to de- 
scribe ; complete details of their various forms will be found in 
the works of COHN, Riant,* Baginski,! and others. I shall 
only in this place mention the principles on which school-seats 
should be constructed. 

1. Dimensions of the seats, — In every class there should be 
school-seats of different sizes. In schools where there are several 
classes it will suffice to have in each class school-seats of two or 
three different sizes. In village schools of only one class, where 
children of the most different ages (from 6 to 14. years) are 
seated together, a greater variety of sizes (4 to 6) is required. 

2. The vertical distance between desk and seat should be only 
slightly greater than the distance between elbows and seat-bones 
( = Jth of the length of the body). Otherwise the child is com- 
pelled, when resting the arms on the desk, to raise the elbows 
too much, whereby the upper part of the body is suspended be- 
tween the shoulders. 



* Hygilne scolaire^ Paris, 1877. 

t Handbuch der Schulhygiene^ Berlin, 1877. 



52 CONSTRUCTION OF SCHOOL SEATS. 

3. The horizontal distance betwixt desk and seat should be 
negative — that is to say, the front border of the seat should ex- 
tend a little way under the desk. If there is a positive distance 
between seat and desk (and in a slight degree if there is no 
distance), the children are obliged when writing to bend the 
body forwards, and to support it by pressing their elbows against 
the desk. On the other hand, when the distance is negative 
(BuCHNER and COHN recommend a projection of the seat 
under the desk to the extent of 2 inches), the child can write 
sitting straight upright, and with his back supported. BERLIN 
has shown that children keep further away from the paper they 
are writing on when their back is supported.* 

The negative distance between seat and desk is good only 
for writing, otherwise it cramps the scholar, and prevents him 
rising from his seat Therefore the desk must be so constructed 
that it can be pushed back or turned up when not used for 
writing. The pushing-back arrangement is better than the tum- 
ing-up, as it can be effected without previously clearing the desk. 
The school-desks of KUNZE, Olmuetzer, and Cardot, attain 
this object in a very simple manner. 

4. The height of the seat (its distance from the foot-board) 
must be equal to the length of the scholar's leg, that is, about -fths 
the length of the body. 

5. The breadth of the seat should be about a fifth of the length 
of the body = 9 to 13 inches. The length of the place for 
each scholar should be at least 25 inches.f 

♦ L.c, p. 34. 

t Most systems allow too small space for little children ; some even (in 
the Paris Schools and Greard's system) as little as 18 inches. 



HOME SEATS. 53 



6. The back of the seat should only rea^h up to the loins* of the 
scholar. The best form for it is a slight curve fitting to the 
shape of the body. 

7. The top of the desk should be sloping, in order that the 
scholar may hold himself as upright as possible. This slope, 
aioreover, facilitates the movement of the arm when writing. 
COHN advises a slope of i to 6 (9^°). The slope should be 
able to be increased, for the purpose of reading, by a mechanical 
contrivance (turning up of a part of the desk). 

8. The breadth oftlie desk must vary according to the size of 
the scholar's body. According to COHN it should be at least 
16 inches. 

Of course it is not sufficient that children should have proper 
seats and desks in the school only ; they ought to have the same 
at home also. This is much more difficult than a suitable 
arrangement in the schools, particularly with respect to the 
xhildren of poor people. The evil is minimised if the home 
work of the scholars is curtailed, but this is a subject to be 
hereafter considered. Otherwise there is nothing to be done 
except for the teacher to advise the parents, or printed instruc- 
tions may be given to tham when the child is first admitted to 
the school. In addition to this the school-doctor should send 
for the parents of short-sighted children and instruct them with 
regard to this and other matters. 

Even when all the conditions are as favourable as possible 
there will always be some scholars who will lean forward and 
bring the eyes too near the object. This is a bad habit which 



* See Appendix by Dr. Roth. 



is seen especially in the subjects of developing myopia 9 
although the slight degree of myopia would allow them ■ 
well to work at a distance of 12 inches and upwards, thej 
have a great tendency to bring everything as near as possible t 
their eyes. The impressive warnings of the teacher in th^ 
school, may effect much in regard to the posture of 
scholars, but he will unfortunately seldom receive much assist^ 
ance in this direction from the parents at home. 




Fig- 5- 



Upright Holdei. 



When admonitions are of no avail an upright holder should be 
employed. Among these that of Kali^mANN, of Breslau, (fig. 3) 
seems to me the best It consists of a metal ring covered with 
rubber, against which the child's forehead leans whilst he looks 
through the ring.* 



• FoBSTER has quite recently recorded the excellent resuhs he has obtained 
by the employment of this upright -holder combined with suitable concave 
Blaases {Archiv f. Augenheilkunde, XIV., p. 309.) See Appendix by Dr. 
Roth. 



PHYSIOLOGY OF WRITING. $5 



(b) Measures AfTecting the Scholars. 

§ 17. — I. Writing, — It has already been mentioned that in 
addition to other factors, the method of writing has a great influ- 
ence on the posture of the scholar. A bad posture of the body 
shows itself in writing on the one hand in an excessive bending 
forwards, on the other hand in a twisting of the body on its axis. 
The consequences of these are curvature of the spine and 
myopia. 

What is the connexion between handwriting and posture of 
the body ? I shall pass over the historical development of this 
question, it may be read at full length in Berlin's report. The 
following are the results of his investigations, which were made 
on a large number of school-children, and which quite lately have 
been corroborated by the examination of persons who write with 
the left hand. 

In the vast majority of cases (93**/o) the oy^s, during writing, 
look at the thick stroke, that is to say during the making of this 
stroke they constantly follow the point of the pen. On the 
other hand the hair stroke is made while the writer only fixes 
his eye on the terminal point to be reached by the pen, and 
guides his pen to this without following the pen on its way with 
his eye. 

Looking at the thick stroke takes place in this way : the writer 
places the fundamental line of vision of his eyes (that is the line 
of combination of the two axes of vision) perpendicularly to the 
direction of the thick stroke, therefore he guides the thick 



S6 UPRIGHT OR SLOPING HANDWRITING. 

stroke along the vertical meridian of his binocular field of 
vision.* 

It follows from what has just been said, that the posture of 
the head (and through that of the whole body) is immediately 
dependent on the position of the thick line in writing, and if that 
has a fixed slope to the line, on the position of the copy-book. 

I have already said that the scholar should sit so that his head 
and shoulder are straight upright and parallel to the border of 
the desk. Such a posture while writing can evidently only be 
maintained when the scholar writes so that the thick strokes of 
the writing are perpendicular to the border of the desk. This 
is effected in two different ways : 

I. — By upright handwriting. — In this the copy-book lies 
straight in front of the middle line of the body, the lines 
are parallel to the border of the table, the thick strokes per- 
pendicular to the lines. COHN, the French official commission, 
Weber, Armaignac, Layet, Schubert and others prefer 
this kind of handwriting. 

2. — Sloping handwriting admits of an upright posture of head 
and body, when performed under the following conditions : The 
copy-book lies in front of the middle of the body, so that the lines 
run up from left to right in a slope of from 30° to 40**. The proper 
slope is obtained when the thick lines of the writing are perpen- 
dicular to the border of the desk. When the sheet to be written on 
in this manner is laid straight in front of the body, the handwriting 

P»^^M^»^M^^— ^^-^— ^^^^l^i^— — ^■^»^i^M^W^»^M— i— ^— — >»W^— ^^»^— H^ ^1 BIM— ^^i^— — 1 — ■■ .1 ■ ■■■^■^—^ Mill ■ ^^^^^— ^ 

* Writing differs from reading, as in the latter the fundamental line of 
vision is dXvfdiys parallel with the lines. 



ADVANTAGES OF SLOPING HANDWRITING. 5/ 

is sloping, ie.y the thick strokes form with the lines an angle of 
about 50°. Sloping writing is thus merely upright writing, 
written on a sheet lying in a sloping position. 

Under all other conditions sloping handwriting must neces- 
sarily entail a twisted posture of head and body. This is the 
case in those (numerous) schools, in which the scholar is required, 
when doing sloping handwriting, to lay the copy-book straight 
before him. Fortunately, the scholars after a time emancipate 
themselves from the improper position of the copy-book they 
have been taught to adopt. But it does not follow that they 
abandon the bad position of the body they have once adopted. 

From what we have said a correct posture of the writer 
IS possible in upright, as well as in (properly performed) sloping 
handwriting. Berlin gives the following advantages of sloping 
over upright handwriting : 

The simplest movement, in order to write continuously on 
one line, consists in a backward bending (extension) of the 
hand; but as this goes but a little way, it is immediately 
succeeded by a" rotation of the arm at the shoulder joint. The 
part of the forearm resting on the corner of the desk forms in 
this manner a fixed point, the centre point of a circular motion 
of the hand and pen's point. If we attempt in this way to 
write with upright handwriting lines parallel to the cross axis 
of the body, we find that we write with an upward slope. 
In order to remain upon the line, we must draw the elbow back- 
wards and towards the right as we advance along the lines. 
This takes place by means of a series of small jerking movements 
of the elbow towards the right 



58 PROPER POSTURE IN WRITING. 

It IS Otherwise with sloping handwriting when written under 
the conditions given above. In that case the direction of the 
upward sloping lines nearly corresponds with the tangent of 
the circular arch which the pen's point describes, when the 
arm is rotated outwards in the shoulder-joint Here there is no 
backward-drawing movement of the arm, and rotation in the 
shoulder-joint alone remains. A very small extent of this 
suffices, for by means of the long arm of the lever, represented 
by the forearm, the excursions of the pen are adequately 
performed. In order that these movements may be well 
accomplished, the surface of the desk should slope slightly. — 
For these reasons BERLIN prefers the sloping to the upright 
handwriting. The latter is more fatiguing, and according to 
Baeumler, more apt to cause writer's cramp.* 

In order to decide the question as to which method of 
writing is preferable, we should be able to compare two schools 
in which, the hygienic conditions being alike, different methods 
of writing are practised, in one the upright handwriting, in the 
other the properly performed sloping handwriting. We should 
see in which school the average posture of the scholar's body is 
the best. Berlin has already instituted investigations on this 
subject, which prove that those children who employ the upright 

* We can convince ourselves of the correctness of what is here said, if we 
write (with a pencil) a number of lines alternately with upright and sloping 
handwriting ; it is best always to write the same words. Whenever we are 
obliged to move the forearm with a jerk, we should mark this interruption 
with a vertical stroke on the place in the line where it occurs ; we shall then 
see how many more such strokes there are in the uprightly written lines, 
especially if the lines are pretty long. 



GERMAN AND ITALIAN WRITING COMPARED. 59 

handwriting on an average hold their bodies better than those 
who use sloping handwriting improperly carried out, but not so 
well as those who are properly taught sloping handwriting. 
But Berlin admits that these trials were made in children un- 
accustomed to upright handwriting ; so that these investigations 
require corroboration. 

Whatever method of writing may be chosen there will always 
remain, in addition to good illumination, good seats and desks, 
&c., very much left to the attention of the teacher, who can 
always do much to ensure a good posture for the children by 
his admonitions. The teacher should not permit a child (pro- 
vided always its acuteness of vision is not too bad) to hold itself 
so that its eyes shall be nearer its book than lO inches. 

A question that is especially interesting to the German 
nation is in reference to the choice between German and Italian 
handwriting. Does the German handwriting require of the 
writer to bring his sheet closer to the eye than the Italian ? 

SOENNECKEN* contends that Roman letters can be read at a 
much greater distance than German. But his experiments only 
refer to print, and they are moreover shown to be inaccurate by 
the reviewer in Zehender's Monatsbldttern^ Berlin was 
unable to detect any difference in the distance at which school 
children held their heads from their copy-books, whether they were 
writing in the German or the Italian character. There is, there- 
fore, no certain proof that a greater approximation of the writer to 

* Das deutsche Schriftwesen und die Nothwendigkeit seiner Reforfn^ 
Bonn, 1 88 1. 

t 1883, p. 187. 



SHORT-HAND. — PRINTED MATTER, 



his work is required when writing German than Italian charactei 
Javal is therefore wrong in ascribing to the use of the Germai 
characters such a great part of the blame for the prevalenci 
of myopia in Germany. If in spite of this all Germai 
authors desire the general adoption of the Roman charactei 
they do so chiefly for international reasons. These certalnlji 
are a complete justification of the proposal to give up the 
German character, which the Germans alone among nations 
have retained since the middle ages, and which form an obstacles 
to international intercourse. I 

COHN warmly advises the introduction of obligatory instruc-fl 
tion in short-hand writing into the higher classes of middle 
schools, for thereby, the time passed by the scholars at the 
writing-desk would be materially shortened. From my ow 
experience I must unhesitatingly join in this advice; it wot 
certainly be still better were the amount of writing generalljfl 
lessened. This applies particularly to middle schools ; 
■universities, in many of which latter the writing of college-* 
exercises is still in vogue. 

§ iS, — 2. Reading. — jAVAL was the first to subject printed 
matter to a thorough scientific examination. He makes a di» 
tinction between visibility and legibility of the letters.* H^ 
says, a letter is visible when one becomes aware of it as i 
actual object, even when one cannot recognize and name it; 
the latter is the case, then the letter is legible. I would emplq; 
the expressions in another sense, as thus : a letter is visibla 



Aima/cs iVOatHsiique, T. LXXXI., pp. 69 and 70. 



LEGIBILITY OF PRINT. 6 1 

when we see it under such an angle that we Cjan clearly dis- 
tinguish all its separate parts, so that, for example, when it is 
an unknown letter we are able to draw a copy of it. The 
letter is legible when we can name it. In order to perform 
this latter act, we do not need to see all its separate parts ; our 
skill in reading often allows us to guess it when we only see 
certain parts of it Still more is this the case when we have to 
do with connected words or sentences. In the sense employed 
by me a letter or a word is legible at a greater distance than it 
is visible. — For reading purposes it suffices that we see certain 
parts of the letter. What are these parts ? They are chiefly 
the thick strokes, the hair strokes belonging to them we guess 
at. JAVAL has called attention to the fact, that the facility with 
which thick letters (Norman letters) are read depends on this. 
I subjoin samples of ordinary type (Roman letters) and thick 
letters (Norman letters) of equal height 

VIRIBUS UNITIS. 
TIBIBIJfi UI¥ITIS. 

The thicker letters are legible at a much greater distance, 
though their hair strokes are quite as fine as those of the 
ordinary letters, and cannot be seen farther off; they are just 
guessed at Hence we employ by preference the thick letters 
for headings, sign-boards, &c. So also the cross strokes at the 
ends of the letters (apices) are not employed merely for the 
purpose of embellishing the letters, but also in order to assist 
us in guessing what they are. They serve for the purpose of 



62 LEGIBILITY OF PRINT. 

embellishment when they are put at the ends of the thick 
stroke ; they prevent these appearing rounded from the effects 
of irradiation {e.g, I). Apices assist us in guessing when they 
occur on the hair strokes, the ends of which they indicate to us. 
Thus they help us to distinguish JB and F from one another, 
at a distance where the hair strokes of both these letters are quite 
invisible to us. 

'Y\i^form of tJie letters influences their legibility. The form 
of every letter should be so characteristic that it should be 
impossible to confound it with other letters. This is unfor- 
tunately not always the case, so that, for instance, the letters c 
and e, n and u can easily be confounded with one another. 
Javal and COHN propose plans by which this can be remedied. 
— The difference between visibility and legibility becomes 
more striking, when we experiment with single letters on the 
one hand, with whole words and sentences on the other, when 
we shall find that the latter can be recognised and read at 
much the greatest distance. Of course much depends on the 
amount of practice in reading the subject of the experiment has 
had. Children have as a rule greater acuteness of vision than 
adults, and hence letters are visible to them at a greater 
distance. On the other hand lines of printed matter must be 
brought closer to them than to adults in order to be legible as 
children have had less practice in guessing. Consequently 
the print of books ought to be larger for the first years 
of instruction than for the later ones. This has long been the 
case in practice, as testified to by the large print of readirtjg 
primers. The large print of the books intended for country 
folks (prayer books, &c.) is partly owing to this reason. 



PRINT FOR SCHOOL-BOOKS. — PAPER. 63 

For those used to reading the legibility of printed matter 
depends not only on the size (height and thickness) and form of 
the letters, but also on the relation of the letters to one another. 
Legibility increases as a rule with the distance between the 
several letters and words (approche), as also with the distance 
between the several lines (interlignage).* 

Moreover the print should be clear and uniformly black. 
The paper should be sufficiently thick so that the print should 
not penetrate through it, and of pure white colour. This 
appears to me to be preferable to the gray or yellow colour 
proposed by many.f 

§ 19. — 3. Drawing and manual work, — If, in drawing or 
manual work the eye must be brought very near the object, 
these occupations must, of course, be fraught with the same 
danger for the eye as reading and writing. 

In order to make this branch of education as harmless as 
possible for the eyes, the following points must be attended to : 

* The desiderata laid down by Cohn for the print of a school-book are 
as follows : i. Height of the n (which Cohn takes as the standard of 
measurement for the height of the whole printed matter) at least 1.5 mill. 
This is the so-called corpus type, which nearly corresponds to the French 
*' philosophie " (of 10 points); 2. Thickness of the n at least 0.25 mill.; 
3. Approche at least 0.75 mill. ; 4. Interlignage at least 2.5 mill. ; 5. Length 
of lines at most 100 mill., with not more than 60 letters in a line. 

t To the reasons given by Cohn for preferring pure white paper, I may 
add another. The greater the difference of light and shade betwixt print and 
paper the further can the illumination be diminished before the print be- 
comes illegible. Hence with bad illumination, black letters on a white 
ground are more easy to read than any other. For this reason pure white 
paper deserves to be preferred to every other, for if we can provide a good 
illumination in the school we cannot always secure it for the home studies. 



64 DRAWING AND MANUAL WORK. 

1. As a rule the only manual works to be taught in the school 
are such as do not require too close looking. COHN and WEBER 
agree in thinking, that manual work requiring the eye to be 
brought nearer than 14 inches to the object, should be forbidden. 
The kinds of work required in ordinary household affairs, and 
which consequently girls must learn, can all be performed at 
this distance. As regards those kinds of work which should be 
prohibited at school as being too fine, they are only such as 
minister to pure luxury, so they may be set aside without 
injury. 

2. Instruction in these two subjects should not begin too soon, 
for, as Berlin has shewn, it is precisely the youngest scholars 
who are most inclined to hold themselves too close to their 
work. Hence it is wrong to set children of six to eight years' 
old, or even while they are yet in 'the kindergarten to copy 
patterns drawn before them, especially when the patterns are so 
small and difficult to see, as for example, the dot-system 
proposed by Stuhlmann. 

3. For drawing, as well as for manual work, the best lighted 
rooms should be selected. If the work must be done in the 
evening (as regards drawing that cannot always be avoided, as, 
for example, in the evening classes in technical schools) the 
artificial lighting should very good. Electrical illumination, 
such as has been adopted in Liege, is certainly the best. 

§ 20. If we always adopt in our schools the best mode of 
lighting that can be obtained, we not only spare the chil- 
dren's eyes, but we also gain a further advantage. Children 
who are accustomed to work in school in a good light, will 



PRIMARY EDUCATION. 6$ 

endeavour to procure the best possible lighting at home. How 

often do we see children doing their home work at a table 
that is far away from the window and receives but little light ; 
the boys read and the girls sew as long as they can in the 
twilight, before the lamp is lighted. When the children see the 
importance attached to good illumination in school, and when 
they enjoy this good illumination for a part of the day, they 
will when at home, select the best lighted part of the room, 
&c. In this way, perhaps, a stimulus will be gradually given to 
that incredible indolence of people owing to which they often 
work in semi-darkness, when they might easily obtain good 
light. 



II. SPECIAL MEASURES FOR THE DIFFERENT STAGES 

OF EDUCATION. 

§ 21. I. Primary education, — As regards age^ no child 
under six years of age should be admitted into the school. In 
many countries indeed the law requires that the sixth year of 
life should be completed, and fixes the duration of primary 
instruction from the sixth to the fourteenth year. 

As regards the Clumber of lessons in primary schools, these 
should be moderate. For the lower classes the maximum for 
" sitting lessons " ought to be three, for the upper four hours. No 
sitting lesson should last longer than three quarters of an hour. 
As sitting still is more difficult for children the younger they are, it 
would perhaps suffice to give only half an hour for each lesson in 

5 



66 NUMBER, DURATION, ARRANGEMENT OF LESSONS. 

the lower classes. Zehender* and CHALYBAEUSf express their 
approval of this arrangement, which has, indeed, been adopted 
in some schools. Between the different lessons there is thus 
a pause of a quarter to half an hour. This, according to some, 
should be filled up with gymnastic exercises. It is certainly 
expedient that the children should leave the school-room during 
the pauses, and the room should then be thoroughly aired. But, in 
place of employing the children during this short interval in 
doing gymnastics, it seems to me that it would be better,J to set 
them at liberty in the open air or (in winter) in a covered space 
where they might amuse themselves as they liked. 

In addition to the sedentary lessons, the singing and 
gymnastic lessons are reckoned as educational lessons. As 
regards the gymnastic lessons, they ought to begin in the 
lower classes as free exercises, and as soon as the children's 
ages allow, gymnastics with apparatus should be employed. 
Gymnastics should be obligatory for girls as well as for boys. 

The arrangement of the lessons should be such that the 
sedentary lessons should be appropriately interrupted by gym- 
nastic and singing lessons. It is a good plan to set the children 
to work in school-gardens (Austria), to easy military drilling 
(France), to playing at out-of-door games (ball-play, &c.) to 
swimming, to excursions in company, &c. 

♦ Ueber den Einfluss des Schulunterrichis auf die Entstehung der Kurz- 
sichtigkeit Stuttgart, 1880. 

t Vierteljahresschrift fur Gesundheitspflege^ Bd. IL, p. 55. 

X See Roth, IV. International Hygienic Congress^ Geneva, 1883, Vol. 
II., p. 402. 



COPY-BOOKS, WRITING MATERIAL. 6/ 

Home work were better dispensed with among the lower 
classes of primary schools ; in the upper classes they should not 
extend beyond one-and-a-half to two hours daily. 

As regards the Wtethod of instruction^ mention has already 
been made of the chief points appertaining to reading and 
writing. The first instruction should begin with reading ; after 
six months or one year a commencement of learning to write 
should be made. 

In order to learn sloping writing it is not necessary to have 
sloping ruled lines in the copy books and slates. If the copy 
book be placed properly before the child, the writing' necessarily 
gets the proper slope. Deviations from a given degree of slope 
are of no consequence, and Berlin is right in proposing to 
dispense with sloping ruled lines, because they compel the 
children to look more closely. The same may be said of 
Adlers* model writing copy books, which COHN objects to. 
All copies which are chiefly or quite made up of fine lines or 
points difficult to see, should be rejected. 

As regards the material for writing on^ hitherto the slate has 
been usually employed for the commencement of writing lessons. 
Horner* showed that, as regards visibility, writing on the 
slates is to writing with ink on paper as 3 to 4. This together 
with the shiny surface of the slate causes the writing scholar 
to assume a bad posture. Hence white slates are preferable to 
black ones, as suggested by COHN. Such are the artificial white 
slates for writing on with a peculiar lead pencil, which are made 

* Deutsche Vierteljahresschrift Jur offentliche GesundheitspflegCy X., p. 742 



68 OVER-PRESSURE IN SCHOOLS. 

by Thieben, in Pilsen. The trials of this, made by COHN, 
showed that as regards the visibility of the writing, the black are 
to the white as 5 to 6 (later trials give as 7 to 8). 

§ 22. — 2. Middle scliool education, — ^The middle school is that 
stage of education which is attended by the greatest dangers for 
the eye. The primary school makes very few short-sighted. 
Hence the number of myopes who enter the lower classes of the 
middle school is small. During the period of the middle school the 
number of myopes gradually increases up to an average of 57 **/^, 
(see the curve copied from COHN on p. 30). I have pointed out 
above what influence the defective lighting, the seats and desks, 
the type of the books, &c., have in the production of this terrible 
increase of short-sightedness. The injurious influence of these 
factors is particularly increased by the excessive amount of work 
which is imposed on the scholars of the middle school. It is par- 
ticularly in Germany that the scholars are overworked to a very 
great degree. DUERR* gives some interesting calculations on this 
point. In Germany during his middle school years, the scholar has 
to devote 25,000 hours to his school and home lessons, 650 only 
of which are spent in gymnastic lessons. He compares the 
number of hours which the scholar has to give to his lessons 
between his loth and 19th year in Germany, France, and 
England. They are as follows : — 

Hours from loth to 19th year. Working hours. G)rmnastic hours. 

in England 16,500 ... 4,500 

„ France 19,000 ... 1,300 

„ Germany 20,000 ... 650 

* V. Graefe's ArchiVy Vol. XXIX., part I., p. 143. 



OVER-PRESSURE IN SCHOOLS. 69 

Nothing could more strikingly demonstrate the absurd 
method of instruction in the German schools. Here we see at 
the same time the true cause of the frequency of myopia in 
Germany. It is not the German writing or print, not the too 
long lines or the influence of nationality, but the excessive work 
imposed on the scholars. This overwork has a twofold reason : 
too many subjects and a faulty mode of teaching. — The increase 
in the number of subjects taught is owing to the unexpected 
pre-eminence which the natural sciences in particular have 
•obtained in recent times. The recognition of their importance 
for every one has necessarily led to their introduction into the 
programme of studies of the middle schools, which have at the 
same time retained the old subjects of study in their full extent. 
But these, owing to the retention of old faulty modes of teaching, 
have become so onerous, that many influential voices have been 
raised for the omission of a portion of them. This is not the 
place to discuss this point. 

All are agreed that the time devoted daily to work by the 
middle school scholars ought to be diminished. Some are of 
opinion that this can be effected whilst retaining all the subjects 
of study in their present extent, if a better method of instruction 
were adopted. Others think that this alone would not suffice, 
but that some of the subjects of study {e,g, the dead languages) 
should be cut down. I must say I agree with the latter opinion. 
Like many other university teachers, I see every day that the 
students in the technical branches are very insufficiently pre- 
pared for the university, whilst at the same time their knowledge 
of the dead languages is so defective, that it does not compen- 



70 GYMNASIA AND TECHNICAL SCHOOLS OVER-FILLED. 



sate for their deficiencies in the former. How can we reined] 
this evil ? 

The authorities should endeavour to control the admissioi 
to the gymnasia and technical schools. 

Many of the young people belonged to the middle schi 
in the narrower sense (upper public schools), which stai 
between the lower public schools and the gymnasia and retaia 
the scholars till their sixteenth year. These would supply them 
with a better defined education and one more suitable for their 
purpose than the gymnasia and technical schools. Still more 
worthy of recommendation are the commercial and trade 
schools, where without over-burdening the scholars, in additii 
to general education they are taught a number of subjects usi 
for a business life. 

But in the other middle schools (gymnasia and technii 
schools) in order to do away with overwork, the instruction 
in the school and the work to be done at home must be suitably 
r^ulatcd. This is more especially necessary in Germany where 
overwork is carried to the greatest lengths. 

And first let us consider the school-lessons. These are dividi 
into sedentary lessons and lessons of corporeal exercise. To 
latter belong singing and gymnastic lessons, to the former, 
other lessons which require either exertion of the mind 
of the eyes, or of botli together.*— As regards ovenvork it 



-ade 

tioofl 

leiufl 

licafl 



* This division is more convenient than that into scientific and technics 
lessons ; the technical lessons include singing, gymnastics, dra.wing, an4 
writing. It is a mistake to include these four subjects in the same categorjj 
Drawing and writing lessons are attended with as much injury to the e; 
and the body as lessons in science. 



NUMBER OF SCHOOL LESSONS. 7 1 

only the sedentary lessons that have to be considered. The 
Strasburg Commission proposed to commence the lower class 
with 18 sedentary hours per week and to increase them gradu- 
ally to 30 hours in the upper class. Alexi is in favour of a still 
greater reduction. According to his recommendations to the 
German Society for public Hygiene,* the number of hours 
for sedentary lessons per week should be 24 in the gym- 
nasium (only in the upper classes 26) and in the technical 
schools 28. — Everyone can realise for himself the mental ex- 
ertion required to follow with sufficient attention a lecture 
lasting a full hour. If the scholar has to do this for four hours 
daily, that is a great effort and to my thinking the maximum 
that should be required from him. It must be borne in mind 
that the less clever scholar will have enough to do to digest 
mentally what he has heard in these four hours, whilst the more 
clever scholar gets at home additional instruction in music, 
languages, &c. ; further, that besides his studies at home the 
scholar ought to have time for walks, bodily exercises, &c. 

The arrangement of the instruction should be such as to allow 
an occasional relaxation of the accommodation. Hence it will 
be necessary to adhere to the principle already laid down for 
primary schools, that each lesson should only last |ths of an 
hour. In the quarter-hour pause between two lessons, the 
scholars should leave the room in order that it may be aired, 
and amuse themselves according to their fancy in the open air 
or in a covered locality. Further, care should be taken that 



* Deutsche Vierteljahresschrift fiir offentlichc Gesundheitspflege^ Bd. XL, 
p. 46. 



72 HOME WORK. 



two lessons with writing should not come in immediate succes- 
sion. Finally it is of the greatest importance so to distribute 
the lessons, that the series of sedentary lessons should as far as 
possible be interrupted by lessons involving bodily exercises. 
A proper arrangement of this sort would necessitate an increase 
of the gymnastic lessons, which according to most of the sug- 
gestions are not more than two per week; such an increase 
appears to me to be urgently required. 

Like the lessons in school, the work at home required from 
the scholars of gymnasia and technical schools has gradually 
risen to an extravagant height. 

The scholars of the Berlin gymnasia, according to Alexi, 
have to devote 33 hours, those of the Dresden technical 
schools* as much as 36 hours per week to home work, so 
that the students of the upper classes have to work every day 
from 7 a.m. till 10 p.m. What time have they for recreation ? 
As regards the value of the work performed, we may say of it 
as we say of manual work, that it is in the inverse ratio of 
the duration of the daily work. 

The Strasburg Commission recommends that the hours of 
home work should rise from three per week in the lowest class, 
to 12 — 18 in the highest class, but should not exceed this 
maximum. This is quite right. A diminution in the amount 
of home work is doubly necessary, because it must often be 
performed in a bad light, on an unsuitable seat, and under many 
other unfavourable conditions. But it should not only be 

♦ NiEDNER, Deutsche Vierteljahresschriftfuroffentliche Gesundheitspflege^ 
Bd. X., p. 74. 



HOLIDAYS. 73 



diminished but arranged in a sensible manner. It has therefore 
been proposed to ask the parents of the scholars to come at 
the commencement of the school year, and to ask them what 
lessons they will get their children to do at home. The op- 
portunity might be seized to give the parents the necessary 
instructions. Should it turn out that the scholar is not par- 
ticularly clever, the teacher should earnestly warn the parents 
not to fatigue him with any out-of-the-way subjects. 

Sundays and holidays , the real object of whix:h is the recrea- 
tion of the scholar, should not be interfered with by home 
lessons. The vacation is best spent, when the circumstances of 
the scholar will allow it, in expeditions on foot. Quite apart 
from the great advantages of this kind of travelling on body and 
mind, it has a specially good influence on the eyes. Arlt made 
the observation on himself, and it has been repeated by many 
others, that myopes generally return from such a journey some- 
what less short-sighted. The long-continued rest of the eyes 
probably effects a complete relaxation of the accommodation and 
therewith a diminution of the myopia to its true degree.* 

The education of our youth stands in need of a thorough 
reformation, the necessity for which is every day more apparent 
and insisted on. The body can now no longer be neglected for the 
sake of the mind as has hitherto been the case. The model for 
all is the education of youth as practised in England, in which 
what are called " athletics," play a great part. To these belong 

* COHN (Hygiene der Augen^ p. 165) found that complete rest of the eye 
for three weeks has the same effect as an atropine treatnjent, that is to say 
diminution of the degree of myopia. 



74 TREATMENT OF MYOPIC SCHOOL CHILDREN. 

swimming, rowing, riding, running, archery, and a great number 
of games which are played in the open air and demand 
bodily agility. 

A disproportion between the knowledge to be acquired 
and the time allotted to its acquisition is found in the upper 
schools as well as in the middle schools. But the scholar in the 
upper school is not subject to such strict rules ; he can, if he 
please, prolong the time given to the acquirement of the 
necessary knowledge. But the other evils I have alluded to as 
incident to the middle schools, exist in the upper schools in, if 
possible, a still greater degree. Seats and desks, lighting, type 
of books, with few exceptions, leave much to be desired. In 
addition to this, there is the unfortunate habit, practised in 
Germany, in particular, for ages, of writing down many lectures, 
and studying these ill-written college scribblings. 

III. MEASURES APPLICABLE TO EXISTING MYOPIA. 

§ 23. This is not the place to speak of the therapeutics 
of myopia ; that will be found in the manuals of ophthalmic 
medicine. I may be allowed to make only a few remarks 
upon it. 

In the slighter cases of myopia (up to about 4 D = Vp)^ th^ 
teacher, or still better the school-doctor, should send for the 
parents and instruct them in the essential rules for the guid- 
ance of myopes. 

Many short-sighted scholars wear spectacles, mostly such 
as they have bought for themselves without medical advice. 

« 

The consequence of this is that many use unsuitable glasses. 



COMMISSIONS FOR STUDYING SCHOOL QUESTIONS. 75 

COHN found that about 37% of the spectacle -wearing scholars 
wore too strong glasses, Erismann found this the case with 
19°/^. Medical supervision is therefore urgently necessary, and 
no scholar should be permitted to wear spectacles until he is 
able to show a medical prescription for them. 

Should short-sighted scholars wear spectacles ? Myopes of 
the lowest degree do not require them, if these are able to see 
the school board when sitting on one of the front forms. Myopes 
of the middle kind must for that purpose evidently wear glasses. 
Extremely short-sighted persons must be regarded as unwell. 
Every such case should be carefully examined by the school 
doctor, in order that he may be able to point out the proper 
means to be employed. The physician should particularly call 
the parents' attention to the fact that their child is not suitable 
for every calling. 

IV. MEDICAL SUPERVISION OF SCHOOLS. 

§ 24. It is but a few years since medical men have been 
allowed to say a word about schools. Surgeons and oculists 
were the first to direct attention to the dangers to which school 
exposes many children. Then learned medical societies began 
to busy themselves with this question, and some municipal 
bodies went so far as to organise a medical supervision of the 
schools under their control. Lastly came the Governments 
which appointed Commissions which were to occupy themselves 
with this question. In France, on the 17th of June, 1880, the 
Ministry promulgated regulations regarding the building and 
arrangement of schools, in which modern hygienic requirements 



*]& MEDICAL SUPERVISION OF SCHOOLS. 

are attended to. In 1881 the Government nominated a Com- 
mission, partly composed of medical men. This Commission 
visited some schools, and in the following year issued a report 
through Dr. Cartel * About the same time a Commission 
composed entirely of medical men appointed by the Governor 
of Alsace-Lorraine made their report. Further, a Commission 
composed of medical men and schoolmasters was appointed 
by the Hessian Government. Besides these a Commission was 
appointed by the Wirtemberg Government to which BERLIN 
and Rembold presented a report in 1882. All these Commis- 
sions recommended the appointment of school-physicians who 
should undertake a regular inspection of schools. Finally the 
precise recommendations of COHN were communicated to the 
International Hygienic Congress at Geneva in 1882, which 
adopted the proposals of COHN. 

Although the Governments have not yet pronounced any 
generally applicable judgment relative to medical supervision, 
some towns and departments have already spontaneously 
instituted a regular medical school service. Brussels was the 
first to do this. The medical school inspection hsis been in 
operation since 1874. It includes all the schools of the city, 
including the kindergartens. The school physicians have to 
inspect every school three times every month, and to report 
particularly on the hygienic conditions of the schools and the 
state of health of the scholars. Especial attention is given to the 
eyes (on account of the trachoma that prevails in Belgium). In 

* Annates d* hygiene publiquc^ 1882, Vol. VII., p. 367. 



MEDICAL SUPERVISION OF SCHOOLS. ^*J 

Belgium the example of Brussels was followed some years later 
by Louvain, Antwerp and a number of other towns. 

In the neighbouring country, Holland^ the law, since 1865, 
gives the state-appointed physicians the right to visit the schools 
and to insist upon alterations, but it does not compel these 
physicians to do this, so that a regular inspection of the schools 
does not yet exist. 

In England a medical department in the Local Government 
Board was established in 1872. To it is confided the medical 
supervision of the schools. 

In France the department of the Seine was the first to 
establish a medical school service in 1879. It has this defect,, 
that it is confined to the communal schools, but does not 
extend to the koles libres (private schools). The school physi- 
cians who are nominated by the Prefect for three years, are 
required to visit every class twice a month. They have first to 
inspect all the localities and then to examine the scholars. They 
enter their observations in a book, which is kept in the school 
but in addition to this they must within twenty-four hours send 
a report to the Maire concerning their visit (in the shape of a 
filled up formulary). The example of the department of the 
Seine has been followed by a number of provincial towns, such 
as Havre, Bordeaux, Lille and Lyons, which have also instituted 
a medical service in the schools. 

In Germany^ Frankfort-on-the-Main appointed a town phy- 
sician on the 1st of April, 1883, to inspect the schools. In 
Switzerland^ Geneva is about to establish a school inspection. 

From this it will be seen that the medical inspection of 



78 DUTIES OF THE SCHOOL PHYSICIAN. 

schools is still in an incipient stage, what at present there is of 
it is due to the initiative of some enlightened municipalities. 
But the powerful action of the government is required, in order 
that this inspection may be carried out in the whole country, if 
possible according to some uniform plan. 

§ 25. School physicians, — As regards the supervision of a 
school many points are to be considered. The general hygienic 
conditions of the building, the state of health of the children in 
general, the outbreak of infectious ' diseases among them, the 
posture of their bodies in reference to spinal curvatures, finally 
the eyes of the scholars. It is not sufficient that the supervision 
should embrace all necessary points, it must also be precise and 
reliable. If we are unable to obtain good supervision of the 
schools it is better to require none at all ; if imperfectly per- 
formed it only keeps the parents in a false security without 
affording any protection to the children. 

The necessity of a good intelligent supervision constitutes, 
perhaps, the main difficulty to be overcome in the introduction 
of a school supervision. As is evident the supervision of a school 
demands an amount of knowledge which cannot be expected of 
every medical practitioner, because it is to a great extent of a quite 
special nature. I may mention a knowledge of hygiene in refer- 
ence to school buildings, and especially a knowledge of the way 
to examine the eye. Austria is the country where clinical instruc- 
tion in ophthalmic medicine has been longest practised and 
made compulsory for all medical students. But of my own 
experience I can testify that in spite of this it is very badly 
provided with practitioners endowed with a knowledge of oph- 



MEDICAL INSPECTION OF PRIMARY AND MIDDLE SCHOOLS. 79 

thalmic subjects. It is only during the last few years that all 
the universities in Germany have established eye-clinics ; in 
Paris a university eye-clinic has only existed for four years ; in 
England a course of eye diseases is not obligatory, and accord- 
ingly few medical students attend it. How then can we expect 
from ordinary practitioners a special acquaintance with ophthal- 
mic medicine? How long should we have to seek before 
finding a physician who possessed a case of spectacle lenses ? 
Consequently we cannot expect even from good medical practi- 
tioners the ability to determine the refraction of school children ; 
-even should the study be compulsory, we could not rely on 
obtaining satisfactory results. Every oculist knows that it is 
not always an easy task to determine the refraction. So that 
although as regards the other points appertaining to the super- 
vision mentioned above, the knowledge of a good medical 
practitioner may be adequate, it may be very inadequate in 
respect to the examination of the eyes. Therefore, if the inspec- 
tion of schools is to be effectually performed, it must be entrusted 
to specially qualified medical men. For this the medical men 
appointed by the state (parish doctors, district doctors, or what- 
ever they are called) must be employed. In some countries 
these men have to undergo an examination (Physicatsexamen) 
upon subjects specially appertaining to their office, such as 
hygiene. In future more care must be taken that they arc 
sufficiently versed in the hygiene of the eyes than is the case at 
present To medical men with such requirements the super- 
vision of the schools should be entrusted. But doctors with State 
appointments are in no country numerous enough to make a 



D short, j 
lal coi^H 
regards 



constant inspection of all the schools In the country. So I think 
that there should be various degrees of inspection according to 
the character of the school. In the primary schools, more par- 
ticularly the vill^e schools, the hours of instruction are so short, 
that some of the dangers incident to schools, such as spinal c 
vatures and short-sightedness, are little to be dreaded. As n 
the latter danger I may remind the reader that COHN I 
only 1,4 °/^ of myopes among the children of village schools. 
The supervision of the village schools may therefore be entrustet 
to ordinary medical practitioners, and a determination of ' 
refraction of the children need not be required. On the oUi 
hand the middle school should be under the supervision of tbl 
district (parish) doctor. In tOH'ns where there are oculists thq 
should be employed to assist the district doctor in the examtn^ 
tion of the eyes. 

I shall now mention those points appertaining to the super- 
vision of schools, which refer to the refraction of the eyes. I 
shall confine myself to these in this place ; hereafter I shall saji 
something about the supervision of schools in reference 1 
trachoma. 

I. The government, acting on the advice of a competei 
commission, should lay down rules in reference to the construj 
tion of school buildings, the school furniture, the subjects to t 
taught, the method of teaching, the school books, &c." 



• By a ministerial ordinance of the 13th May, i879,there was establishiB 
in Paris a pedagogic museum, with library attached, for the reception of • 
objects bearing on school hygiene. In Brussels, also, a scholastic miiseurti 
has existed for the last four years. 



WITH REGARD TO REFRACTION. 8 1 

regards school buildings and furniture, the regulations thereto 
appertaining must be strictly observed in the erection of all 
new schools. Hence the plan of the school to be built must be 
submitted to the authorities for their examination and approval. 
As regards schools already existing a minimum of requirements 
should be fixed, which no school should fall short of. 

2. All the schools in the country should be examined by 
competent Commissions, in order to ascertain if they come up 
to the required minimum. Should this not be case, the Commis- 
sion must decide whether any alterations should be made in the 
school, or whether it should be entirely shut up. 

3. The school physicians should be nominated by the 
Government, and they should receive an adequate remuneration 
for their services. In a locality where there is a district phy- 
siciaiT, he should be entrusted with the oversight of the schools 
In places where there is an oculist, to him should be committed 
the examination of the eyes. 

4. In the middle schools (town schools, commercial and 
trade schools, gymnasia, technical schools, &c.), at the com- 
mencement of the school year the refraction of all the scholars 
should be determined and entered in a book. The doctor 
has to settle how they are to sit with regard to their visual 
powers ; further, what scholars are to wear spectacles and 
the kind of spectacles they require ; so also, if in consequence 
of the state of their eyes they have to dispense with some 
subjects (^.^., drawing). Moreover in cases where it appears 
necessary he should send for the parents in order to acquaint 



82 EYE DISEASES CAUSED BY GENERAL DISEASES. 

them with the hygienic precautions the eyes of the child 
require. 

The school physician ought to report the results of his 
examinations of the eyes, as well as his other observations, to 
the proper authorities. 

As already observed, these points refer exclusively to the 
prevention of myopia. — It would be a material assistance to the 
efforts of the State and of the physicians appointed by it, if 
those destined for the post of teacher were to receive suitable 
instruction in hygiene. This wish has been already expressed 
in many quarters. If this were done, then teacher and school 
physician would be able to act in conjunction for the advantage 
the scholars. 



Part IV. 



Eye-Diseases consequent on General 

Diseases. 

The farther we advance in medical knowledge, the more 
numerous become the eye diseases which we can refer to general 
diseases or to affections of certain organs. Certainly we do not 
take matters so easily as the old humoral pathologists, who simply 
referred every disease to some deterioriation of the humours. 



AFFECTIONS OF THE CORNEA. 83 

Not only do we require proof of the connexion, we endeavour 
also to ascertain how it takes place. With regard to many eye 
affections, we have already succeeded in ascertaining their 
dependence on other diseases of the body. This is especially 
true of affections of the deeper parts of the eye, namely the 
uveal tract, the retina and the optic nerve. In many cases no 
special prophylaxis relating to the eye is possible ; it can only be 
directed against the general disease from which it springs. 



Chap. I. Acute Febrile Diseases. 

The eye is much more frequently affected in these than is 
generally supposed. Owing to the gravity of the general 
malady, the affections of the eye, especially those of its deeper 
parts, are easily overlooked. The patient lying grievously ill, 
makes no complaint of disorders of vision, and so, as a rule, no 
minute examination of the eyes is undertaken. Should the 
patient recover, the slighter affections of the eye generally recover 
spontaneously, and so remain unnoticed. If the eyes have been 
more seriously affected, the oculist often does not see until long 
afterwards the cases of closure of the pupil, atrophy of the optic 
nerve, &c., which remain after the cessation of the disease. 

Most of the diseases coming under consideration in this 
place are infectious diseases. The eye diseases incident to them 
have much in common ; I shall consider them in the order in 
which they attack the several parts of the eye. 

§26. — I. Affections of the cornea, — Persons attacked by a serious 
disease such as typhus, cholera, pyaemia, meningitis, &c., often lie 



84 KERATITIS XEROTICA, HYPOPION. 

for several days half or quite unconscious. The eyelids are half 
open, between them the lower third of the cornea lies exposed. 
It is generally covered with yellow dried secretion ; if we remove 
this crust we find beneath it the cornea dry, lustreless, dim, or 
even ulcerated. When such patients do not die, as usually 
happens, but recover, they may have dense cicatrices in the 
cornea, or they may lose one or both eyes completely. This 
keratitis was formerly regarded as the effect of depressed inner- 
vation and designated as neuro-paralytic. Now we know, 
thanks especially to Feuer's labours* that this keratitis is a 
consequence of the drying of the exposed cornea. On this 
account Feuer called it keratitis xerotica. This affection may 
be prevented by the care of the medical attendant. Patients 
who are not able to close their eyes completely, and in whom 
the first signs of this drying process show themselves, should 
have their eyelids immediately closed. This is best done by 
means of narrow strips of court plaster. Every practitioner 
should know this. 

Another form of keratitis, abscess of the cornea (hypopion 
keratitis) is chiefly met with in small-pox. The cornea is, as a 
rule, first affected when the pocks have already passed their 
culmination, consequently in the stage of desiccation, or during 
convalescence. There are relatively few observations on the 
frequency of eye affections in small-pox. I subjoin some of 
these. 



* Wiener med, Presse, 1877, p. 43. 



ABSCESS OF CORNEA IN SMALL-POX. 85 



» 



» 



Observer. Number of small Of these the eyes 

pox cases. were affected in : 

Hebra 12,000 ... i7o 

Manz* 2,000 ... 1.6°/^ 

ADLERt I. Vienna Communespital — ... 6°/^ 

11. Vienna Communespital 1,182 ... 2.9°/o 

Vienna Children's hospital 706 ... 9°/^ 

MONTAGNE D. M AKUNA J ... — ... 9.77^ 

Oppert § 2,755 ... ii7o 

The percentages given in the above table refer to eye 
diseases in general, not merely to abscess of the cornea. The 
frequency of these complications varies considerably ; it depends 
to a great degree on the severity of the epidemic. The more 
severe the small pox is in general, the greater is the danger to 
the eyes. Adler observed a series of 100 cases of smallpox 
in which the eyes were affected, a number of whom were 
blinded. This accident, however, only happened to patients 
who died of small-pox, consequently to the severest cases. 
None of those who recovered lost an eye. 

The eye affections observed were of very different kinds, but 
we shall only consider those in which the cornea was affected. 
Adler had among 165 variolous opthalmias, 70 cases of corneal 
affection (42°/^), Landsberg || among 270 variolous ophthalmias, 



* Bericht der naturforsch, Gesellschaft in Freiburg^ 1872. Manz only 
^ves the severe cases of eye affections. 

t Vierteljdhresschrift fiLr Dennatologie und Syphilis^ 1874. 

X Brit Med, Joum,^ 3rd June, 1882. 

§ Deutsche Klinik 1872. Oppert includes also the slighter cases. 

II Beitrage zur variolosen Ophthaltnie^ Elberfeld, 1874. 



8 1 cases of corneal affections (30°/ J. These authors cnumcrati 
all the cases of variolous ophthalmia, severe and slight, amoo) 
the latter many were simple conjunctivitis. If we confine 
ourselves to the severe cases of eye affections only, we find that 
most of these were affections of the cornea. Thus COCCIUSB 
found among 58 variolous ophthalmias the cornea implicated 4 
times (767J, Manz in 32 cases, 24 times (7S°/J. 

The following data give us information respecting 
gravity of the corneal affection: In 81 cases of varioloi 
keratitis, reported by Landesberg, the eye was lost 12 timffl 
Of Manz's 32 cases, 4 went on to phthisis corner, 2 to tot4 
staphyloma corneie, and 11 to the formation of leucoma. — In 
any case, therefore, variolous keratitis is a veiy serious disease, 
which often causes loss of sight ^H 

Before the introduction of vaccination, snrall-pox was J^| 
extremely widespread disease, and consequently furnished a 
very great contingent of blind people. According to Carron DE 
ViLLARS, before the discovery of vaccination 35 °/„ of all blind 
persons in France lost their sight from small-pox, but after the 
Introduction of vaccination not more than 7 7, (Dumont). 
According to STEFFAN,t In Prussia, before the introduction of 
compulsory vaccination 35 °/^, after its introduction 2 7a of ^^ 
blind lost their sight through small-pox. MAGNUS finds the 
present number for Germany 3 °/„, whereas COHN In his statistics 
makes It 3.6 "1^. 



■ Universitdtsprogramm, Leipiig, 1871. 

t WtLS'kbnneH -o/i't, &C., IV. Congress of teachers of the blind a 
fort, 1882. 



CARE OF EYES IN SMALL-POX. 87 

In spite of the general introduction of vaccination, small-pox 
will never entirely disappear, but it is much milder in the vacci- 
nated and hence is much more rarely a cause of blindness. 
Almost all authors who have observed epidemics of small-pox are 
of this opinion. DUMONT found that of the 122 cases of blind- 
ness caused by small-pox, which came to the Hospice des Quinze- 
Vingts, only one single one had been vaccinated, and he had 
been vaccinated unsuccessfully. 

From what has been said the supreme necessity for compul- 
sory vaccination is obvious. As regards the eyes specially, the 
physician who treats the small-pox is in a position to do much 
by care to ward off danger. HORNER justly observes that in the 
treatment of small-pox patients as a rule not sufficient attention 
is paid to the eyes. The eyelids of the patient are covered with 
pocks or crusts, much swollen, and consequently not opened. 
The physician in the small-pox hospital only sees the eyes when 
as the disease declines the patient again opens his eyes. But 
the affection of the cornea may, by this time, have advanced 
considerably. In abscess of the cornea much may be done if 
energetic measures are taken at the beginning of the disease. 
In some cases of abscess of the cornea in small-pox (in one case 
both eyes were affected) I have been able to arrest the process 
by early cauterisation with the actual cautery, and thus to pre- 
serve the eyes which otherwise would most likely have become 
blind. 

It is therefore one of the most important duties of the physi- 
cian in the treatment of small-pox to devote the requisite atten- 
tion to the eyes. The lids should be covered by a linen rag 



88 AFFECTIONS OF UVEA. 

smeared with ointment (HORNER prefers borax ointment). The 
lids are thus rendered supple, they do not stick fast and opening 
them causes the patient less pain. The conjunctiva must be 
cleared of secretion at least once a day, and disinfected (this is 
best done by a solution of corrosive sublimate — i to 5,000). In 
doing this the cornea should always be inspected. As soon as 
the physician notices it to be diseased he must resort to energetic 
measures. 

As in variola so also, though much more rarely, abscess of 
the cornea is found in measles, scarlatina, and typhus. Here the 
same prophylactic measures are to be employed as in small-pox. 

Whqp little children are the subjects of the above-named 
acute exanthemata, of typhus or other severe diseases, they may, 
owing to extreme degradation of their nutrition become affected 
with malacia of the cornea, Malacia is certainly more frequently 
observed in chronic marasmus of children (see page 22.) On the 
other hand children are proportionately more frequently affected 
with scrofulous ophthalmia after acute diseases, and this may 
sometimes continue very obstinately for a long time. 

§ 27. — 2. Affections of the uveal tract, — These occur in the 
course of all acute infectious diseases. Slight affections of the 
ciliary body and choroid, which are only manifested by some 
dimness of the vitreous humour, would probably often be found 
if looked for. REICH* observed in 767 typhus cases (mostly 
convalescents) dimness of the vitreous humour 40 times. Fortu- 
nately the implication of the eyes in the morbid process is 

♦ Zehender's klin, Monatsbldtter^ 1878, p. 487. 



RELAPSING FEVER, CEREBRO-SPINAL MENINGITIS. 89 



seldom so severe as to seriously injure the sight. Cases 
of blindness caused by irido-choroiditis after typhus, variola, 
scarlatina and acute rheumatic arthritis have been observed. 

The affection of the eyes in relapsing fever deserves particular 
mention. This form of typhus, which occurs especially in years 
of scarcity among the poorer classes, is sometimes more, some- 
times less frequently complicated with affections of the uveal 
tract. Knipping* observed in an epidemic at Dantzic eye 
complications in 3.8 ^/^ of the cases, LACHMANNf in 11 °/^, 
LUCHHAU X in 3 J 7^, and Trompetter§ in 6 7^. The frequency 
of eye affections varies greatly in different epidemics. The 

more severe these are in general, the more frequent and more 
severe are the affections of the eye (Estlander). They gene- 
rally involve the anterior part of the uveal tract, namely the iris 
and ciliary body. The disease runs a tedious course and traces 
of it with affection of the power of vision often remain. Complete 
blindness has been observed by several authors, but on the whole 
this is rare. Thus Logetschnikoff|| saw in 750 such cases of 
irido-choroiditis, blindness occur only three times. 

The inflammation of the uveal tract in cerebrospinal 
fneningitis runs a much severer course. Both the epidemic and 
the sporadic forms of this meningitis may be complicated with 
irido-choroiditis. Usually this is of a purulent character and 
leads to shrivelling of the eye with complete blindness. A cure 

* Deutsches ArchivJUr klin. Median^ Bd. XXVL, p. 10, 1880. 

t Ibid, p. 526. 

X Virckov/s Archiv, Bd. 82, p. 18. 

§ Klin, Monatsbldtterf. Augenheilkunde, 1880, p. 123. 

II V, Graefis Archivf. Opthalmologie, Bd. XIV., PL i, p. 353. 



go 



METASTATIC CHOROIDITIS. 



with partial preservation of the sight is rare. This affection i 
chiefly met with in children under five years old. According t 
Magnus patients who have thus lost their sight constitute 1.4 °/J 
of all blind persons. 

A very similar affection is purulent choroiditis which arises 
from tneiasiais from some deposit of pus. From this source 
infective matter enters the circulation and adheres to the ves- 1 
sels of the choroid (seldom to those of the retina) where 1 
develops purulent inflammation. Hence it is to be regardet 
as a phenomenon of pyiemia. The most various kinds of prim 
ary diseases may give rise to it, provided some focus of pui 
is present. This does not need to be large ; metastatic choroiditi 
of both eyes has even been observed after the extraction of a 
tooth. Suppurations in the female sexual organs seem to t 
especially apt to engender the disease, probably on account 1 
the large number of veins in which purulent thrombosis may 
occur. This is most frequently the case in lying-in women ; most 
of the cases of metastatic choroiditis are met with in pucrper^_ 
maladies. 

Choroiditis metastatica is much commoner than is gcncralljj 
believed. In the large lying-in hospitals of Vienna I havi 
often had opportunities of observing it. As patients affected wit] 
it are very seriously ill, and as a rule die, but little attention 2 
paid to the eye affection ; the oculist especially seldom heal 
anything about it. The affected eye is irretrievably lost No^ 
uncommonly both eyes arc simultaneously or successively 
attacked. Notwithstanding this the number of those rendered. 
blind from this cause is small, for very few of those who have t 



AFFECTIONS OF OPTIC NERVE. 9 1 

serious general disease recover (and the same is the case with 
cerebro-spinal meningitis). 

In all these affections of the uveal tract prophylactic treat- 
ment specially directed to the eyes is impossible. When the 
eye disease has declared itself, it ought to be appropriately 
treated, but the physician is seldom able to influence its course. 

§ 28. — 3. Affections of the optic nerve. — As a consequence of 
acute febrile diseaises, there occurs sometimes transient, some- 
times permanent blindness from affection of the optic nerve 
and its central termination. We have only to concern ourselves 
with the permanent blindness. Ophthalmoscopic examination 
reveals in these cases generally neuritis, which terminates in 
atrophy of the optic nerve. Sometimes, however, no patho- 
logical condition can be discovered, and atrophy comes on later. 
Much more frequently such instances of blindness accompany 
meningitis (also epidemic cerebro-spinal meningitis). Affections 
of the retina and optic nerve in meningitis were found : 
By Albutt in 38 cases of meningitis, 29 times 
„ Heinzel „ 41 „ „ 41 „ 

„ BoucHUT „ 59 „ „ 57 „ 

The changes observed in these cases were generally of a slight 
kind, hyperaemia or slight inflammation of the retina and optic 
nerve. But in some cases they attained such a degree, that 
blindness ensued. As in meningitis, so also atrophy of the 
optic nerve comes on after measles, scarlatina, dysentery and 
especially typhus. It is probable, however, that in a number 
of these cases the eye affection is to be ascribed to a complica* 
tion with meningitis. 



92 SYPHILITIC EYE AFFECTIONS. 

Neuritis, with termination in blindness, sometimes occurs in 
■erysipelas of the head. In Magnus's collection of 2,528 cases 
of blindness, two such cases are recorded. The neuritis was 
produced either by inflammation of the orbital cellular tissue or 
by complication of erysipelas with meningitis. 

In all these cases the prophylactic treatment must be 
directed to the fundamental disease, not to the secondary affec- 
tion of the optic nerve. 

Chapter II. Chronic Diseases. 

§ 29. — I. Chronic general diseases, — Syphilis, in consequence of 
its being so widely diffused, is the cause of many eye affections 
which, however, seldom cause complete blindness. COHN* 
found among 20,000 patients i.iS^lo of syphilitic eye diseases, 
and Cocciust among his eye patients 1.16°/^. The number of 
those rendered completely blind by lues is small, according to 
Magnus, 047°/^ of all blind persons. But all Jthe greater is the 
number of those who, through syphilitic eye affections, have 
their sight materially injured. But this ought not to be the 
case, for the prognosis of syphilitic eye affections is generally 
favourable, if they come sufficiently early under treatment Of 
this we may best become convinced in private practice, for syphi- 
litic patients among the better classes are usually anxious and 
seek medical advice early. Opportunities for procuring medical 
advice ought also to be offered to patients of the lower classes. 

* Schubert, l/eder Syphilitische Augenkrankheiten^ Berlin, 1880. 
t Nagel'S Jahresbericht fiir AugenJieHkunde^ 1870^ p. 2c6. 



ANCHYLOSTOMOSIS, CYSTICERCUS. 93 

This question will be considered later on. There is no prophy- 
laxis against syphilitic eye diseases, as we are not able to prevent 
the occurrence of iritis, &c., in a syphilitic person. Prophylaxis 
is only possible against syphilis itself; to eradicate this disease is 
one of the most important problems of hygiene. 

In the first and second parts of this treatise I have already 
spoken of hereditary syphilis, scrofula, leprosy and rachitis. 
Other chronic general diseases which cause injury to the sight, 
and in rare cases blindness, are : Leukaemia, pernicious anaemia, 
scurvy, albuminuria, diabetes, hysteria, chronic rheumatism and 
gout. In none of these cases is prophylaxis possible. 

I may here allude to some eye affections which are caused by 
entozoa. In workmen seriously affected with anchylostomosis 
Rampoldi* observed neuro-retinitis, but all the patients died. — 
Cysticercus in the eye, according to VON Graefe, occurs in about 
one per thousand of eye patients. This is true for North Germany 
where cysticercus is very prevalent. In other countries it is much 
rarer ; Wecker saw, in Paris, among 60,000 eye patients only 
one case. Fortunately cases where both eyes are affected rarely 
if ever occur. A cysticercus can only be developed in the eye 
when proglottides of taenia solium are introduced into the 
intestinal canal. SCHUERMANNf calls attention to the fact, that 
in many places the vegetable gardens are watered with the foul 
water of ditches, in which house drains often terminate. Hence 
it is advisable to wash thoroughly all vegetables that are eaten 
raw (salad). 

♦ Annali di Ottalntolos^ia^ Vol. IX., p. 121, 1880. 

t Mittheilungen aus der Universitdis-Augenklinik zu Milnchen, 1882, 
p. 204. 



94 



CHRONIC DISEASES OF ORGANS. 



5 30. — 2. Chronic diseases of organs. — ^Thesc diseases of the I 
brain and spina! cord furnish the largest contingent. According I 
to Magnus the former contributes nearly 7 7o.' the latter 2.3 °l^A 
of all cases of blindness. COHN ascribes to spinal atrophy ofl 
the optic nerve i.g °/„. According to LEBER one-fourth of all I 
cases of atrophy of the optic nerve depend on tabes, others I 
say still more. 

Diseases of the vascular system lead to blindness by embo- i 
lism or thrombosis of the retinal vessels. Such cases— more par- | 
ticulariy in both eyes — are, however, very rare. On the other J 
hand retinal ha;morrhagcs, with or without retinitis, which injure 1 
the sight very much are common, and are also caused by changes 
in the retinal vessels. — Magnus reckons among these, cases of 
blindness caused by neuro-retinitis after great losses of blood. 

Of diseases of the sexual organs I may mention disturbances 
of the menstrual function, as also various diseases of the uterus^ 
as a consequence of which neuritis resulting in partial or total \ 
blindness has sometimes been observed. 

§31. — 3. Derangements of nutrition of mikmzvn kinds.- 
Under this head should be first mentioned the cases of blindnessB 
which have been observed as consequences of pregnancy, the 1 
puerperal state or lactation. Let us first omit those cases where 
albuminuria, puerperal fever and such like maladies were present, 
therewilt still remain a number of cases in which the pregnancy 
or lying-in apparently ran a normal course. I say "apparently," 
for we must take for granted some still unknown disturbances 



* In this number are included the cases of meningitis alluded to above. 



CATARACT, GLAUCOMA, IRIDOCHOROIDITIS. 95 

which cause the eye affection. This attacks the optic nerve 
generally, more rarely the uveal tract. Whilst in some cases the 
sight is retained, in others permanent blindness occurs. Such 
cases, according to MAGNUS, constitute 0.4 ""1^ of all blind 
persons. 

Senile cataract is not a physiological phenomenon appertaining 
to old age, like, let me say, turning white of the hair. It is question- 
able whether it be a disease caused by purely local changes or by 
some general derangement of the nutrition. Of late years many 
efforts have been made in order to show that some senile cataracts 
are owing to the last named cause. MICHEL attributed it to 
atheroma of the blood-vessels, Deutschmann to albuminuria. — 
It is with glaucoma as with cataract, it is undoubtedly owing to 
some still unknown derangement of the nutrition. Cataract and 
glaucoma are both curable, provided they are taken early and 
treated properly. 

Unfortunately we cannot say the same of chronic irido- 
choroiditis (i. serosa), which we often meet with in persons above 
forty years of age. An insufficient supply of food, and in 
women premature menopause, have been alleged as its causes. 
Many of these cases may be arrested by iridectomy ; others con- 
tinue their course in spite of the operation and lead to blindness. 
According to MAGNUS, of blind persons between forty-five and 
sixty years of age, 15^ °l^ have lost their sight by diseases of the 
uveal tract. A considerable proportion of these cases have been 
contributed by chronic irido-choroiditis. — There is no prophy- 
laxis for it. 



g6 NICOTINE POISONING. 

Chapter III. Chronic Poisonings. 

The chief among these demanding attention are those 
resulting from tobacco and alcohol. They cause affections of the 
optic nerve, which very rarely (if ever) lead to total blindness. 
But all the more frequently are they the cause of weakness of 
vision, which interferes with the working powers of their victims. 
In this connexion, tobacco plays a greater part than alcohol ; in 
most cases the two act simultaneously. 

§ 32. — (a.) Tobacco. — ^The noxious agent in tobacco is the 
nicotine. The dry leaves contain from 1.5 tog^l^ of it, according 
to the kind. In the preparation of the leaves for use, some nico- 
tine is lost, so that the tobacco of commerce contains i./*'/^ of it. 
The proportion of nicotine is greater in the cheaper, smaller in 
the dearer sorts. The cheapest tobacco contains from 2.2 to 

2.5**/^ of nicotine, the middling sorts 1.5 to 1.8°/^, Havana tobacco 
1.8 to 2.27^. 

Heated to 250° the nicotine is volatilized and decomposed. 
But if watery vapour is present, volatilization takes place 
without decomposition. When dry tobacco is smoked, the 
greater part of the nicotine is decomposed by the heat. The 
moister the tobacco— and the cheap kinds are generally damp — 
the greater the quantity of nicotine that passes into the smoke 
with the watery vapour. 

Not only smoking, but chewing tobacco also can produce 
amblyopia (FOERSTER,* AVRESf). Tobacco for chewing is usually 

* Handbuch der Augenheilkunde^ herausgegeben von Graefe and Saem- 
ISCH, Bd. VII., p. 205. 

t Cincinnati Lancet^ nth Feb., 1882. 



CONSUMPTION OF TOBACCO. 97 

rich in nicotine. In many smokers the habit of chewing the end 
of the cigar held in the mouth, may have something to do with 
its bad effects. 

As I have just said, only a small portion of the nicotine goes 
into the smoke, and of this again very little is absorbed. So that 
in order to cause chronic nicotine poisoning, a very considerable 
quantity of tobacco must be smoked. This is shown by the 
circumstance, that of the great number of smokers relatively few 
are affected with tobacco amblyopia. Those thus affected con- 
stitute 0.6°/^ (HiRSCHBERG) to i7o (Foerster), of all eye 
patients. Sichel* says that few can smoke over 12 drachms 
daily with impunity. It is impossible to fix the quantity 
precisely ; this depends not only on the kind of tobacco and on 
the mode of smoking, but also on the individuality and the age 
of the smoker. Among the cases cited by HUTCHlNSON,t there 
are many who did not smoke more than about half an ounce 
daily. HUTCHINSON is of opinion that persons who take no 
alcohol, are less able to resist the effects of tobacco. I do not 
know if this has been proved. It is certain that on the contrary 
inordinate abuse of alcohol favours the development *of tobacco 
amblyopia. Young persons bear tobacco better in general than 
older men. FOERSTER rightly observes that many smokers 
after the age of 40 must diminish their daily ratio of tobacco, if 
they would avoid sleeplessness, loss of appetite, debility, &c. 
By far the greater number of cases of tobacco amblyopia are 
met with in persons beyond 40 years of age. 

* Annates ^Oculistique, Vol. LI 1 1., p. 122. 

t Ophthalmic Hospital Reports, Vol. VIII., p. 456. 

7 



98 TOBACCO AMBLYOPIA. 



HiRSCHBERG* asserts that in Germany every year 3 J 
pounds, in Great Britain i^ pound, in France and Austria 
from 1 1 to 2 pounds of tobacco are consumed per head 
of the population. If we reckon that adult men, from 20 
years and upwards, constitute one third of the total population^ 
and that all these smoke, then the daily consumption of tobacco 
of every smoker amounts in Germany to from 150 to 180 
grains, in Great Britain to 75 grains, in France and Austria 
t6 from 105 to' 108 grains. Some of Hirschberg's patients 
consumed per annum nearly 100 pounds of tobacco consequently 
above 4 ounces per diem. 

The cheap sorts of tobacco contain more nicotine, and are 
therefore more injurious than the dearer sorts. Perhaps it is 
owing to this that tobacco amblyopia is more frequent among 
the poorer than among the richer classes. This may, perhaps, 
be also owing to the greater carelessness of the former. They 
continue to smoke, even when distinct signs of impaired health 
in consequence of smoking are present. Moreover among these 
classes the abuse of alcohol is more frequent, and this favours 
the occurence of tobacco amblyopia. 

In most cases the prognosis is favourable; the malady is 
curable when it has not lasted too long, and the patient aban- 
dons the use of tobacco. Very few of the patients who seek 
medical advice on account of tobacco amblyopia suspect that 
their impaired vision is caused by smoking. Hence it is evident 
that it is important to instruct the public on this subject. If 

* Centralblait fUr Aus^enheilkunde^ 1878, p. 244. 



ALCOHOL AMBLYOPIA, 99 

smokers knew that smoking can cause weakness of sight, they 
would when that occurs feel disposed to leave oflf smoking. 

What can be done to check the abuse of tobacco ? Should 
we open a campaign against it, as against the abuse of alcohol ? 
I do not think we should be justified in doing so. An agitation of 
this sort would find few partisans and eflfect still smaller results. 
According to my idea we should content ourselves with the 
following : — 

1. Instruction of the public with respect to the consequences 
of the abuse of tobacco. 

2. Diminution of the quantity of nicotine contained in 
tobacco, especially the cheaper sorts. There are various processes 
for extracting the greater part of the nicotine from the leaves 
without impairing the aroma of the tobacco. It will only be 
necessary to find out the best and cheapest of these, and to 
bring them into operation. At present in countries where 
tobacco is a government monopoly, the government gains from 
800 to 900 °/^ in the manufacture of the cheap sorts ; it might 
therefore very well spend some of its profits in rendering the 
tobacco less injurious to health. 

§ 33. — (Jf.) AlcoIioL — ^The abuse of alcohol sometimes causes 
amblyopia, the symptoms and course of which greatly resemble 
those of tobacco amblyopia. In most cases tobacco and alcohol 
act together. — In order that chronic alcoholic poisoning should 
occur, two factors are required : i. The taking of a suflSicient 
quantity of alcohol for a long time ; 2. The presence of fusel 
oil in the drink. Both of these generally come into play in the 
case of spirit drinkers. Hence an agitation has very properly been 
directed against drinking spirits. 



100 LAWS AGAINST ABUSE OF ALCX>HOL. 

The drinking of spirits among the people increases, generally 

speaking, as we go north. In some localities it is enormously 
great. In the Dutch province of Groningen the annual con- 
sumption of Geni^vre (the cheapest kind of spirits) amounts to 
62 pints per head of the population, therefore certainly more 
than 124 pints for every grown up man. For the workmen in the 
" Poldem '' and on the dykes the quantity reckoned is i| pints of 
spirits per diem per head, but many exceed this quantity.* 

The proportion of fusel is very great in the commoner sorts of 
spirits, as potatoes are chiefly used in its manufacture, that being 
the cheapest material, and they furnish a large quantity of fusel 
Moreover as little as possible is done in the way of rectifying the 
product. 

Alcohol does so much harm that governments have felt it 
their duty to endeavour to mitigate the evil by special enact- 
ments. Of all spirit-drinking countries Belgium is the only one 
which forms a discreditable exception in this respect. All other 
civilised countries in which spirits are drunk have regulations on 
the subjectt These represent all degrees of stringency, com- 
mencing with the State of Maine in North America, where the 
sale of spirituous liquors is totally forbidden (except for medical 
purposes). The requirements with regard to the legislation con- 
cerning spirits have often been formulated. The following are 
the chief points : 



* J. Beau JON, Revue de Belgique, 1883. 

t Metman, Etude sur les legislations Europednnes relatives aux debits de 
boissons alcooliques, Paris, 1879. 



LAWS AGAINST ABUSE OF ALCOHOL. lOI 

1. The State should take care that the spirits sold should be 
good, i£., free from fusel. 

2. It should enhance the price of spirits by suitable excise 
•duties, and on the other hand favour the production and sale of 
milder alcoholic drinks (beer, cider). 

3. The number of drinking shops should be diminished by 
making the license for them dear and difficult. The number of 
licenses granted should be regulated in proportion to the number 
oi the population.* The sale of spirits by other than licensed 
persons should be severely punished. 

4. On the other hand the establishment of tea houses and 
soup kitchens, of warm rooms and such like places, should be 
encouraged as much as possible. 

5. The existing spirit shops should be carefully watched by 
the police. Severe punishments and withdrawal of the license 
should be threatened to such as sell bad (adulterated) spirits. 
No spirit should be sold to minors or intoxicated persons, &c. 

6. Any one found in the streets intoxicated should be 
punished by fine or imprisonment. 

7. A notorious drunkard should be treated as a dissipated 
•character and placed under restraint. Habitual drunkenness 
should form a ground for divorce. 

8. The action of temperance societies, or societies for tea 
houses and soup kitchens, &c., may be of great use. 

* In Holland, according to the new law, in communities above 50,000 
souls one license is granted for every 2,500 inhabitants ; in smaller com- 
munities one license for every 250 inhabitants is granted as the maximum. 
For the purpose of comparison, I may mention that in Belgium one license 
is granted for every 44 inhabitants. 



LEAD NEURITIS. 



5 34. — (c.) Lead. — Chronic lead poisoning sometimes cau; 
optic neuritis, from which atrophy of the optic nerve ma] 
result. If the affection is not too severe and if treatment 
resorted to in time the case may be cured. Otlierwi 
weak sight or even total blindness may come on. Ol 
symptoms of chronic saturnine poisoning always precede tj 
eye affection.* 

Chronic lead poisoning can be produced in two different 
ways: I. The lead is introduced into the body with the foot 
This happens when food is prepared or kept in vessels col 
taining lead, or when it is adulterated with substances containinj 
lead. 2. When the workman is brought into contact wil 
substances containing lead. 

Poisonings by lead in food, are, as a rule, slight in degree 
and hardly ever lead to injury of the sight. More frequent 
and more serious are the lead poisonings of workmen whO' 
come in contact with substances containing lead. 

The measures to be taken in order to protect the workmen 
are as follows: For substances containing lead should 
substituted, where possible, others of an inocuous character^ 
as has been already done in the preparation of many colours. 
In working up substances containing lead, manual labour should 
as much as possible be replaced by machinery. It is very 
important to avoid exposure to the dust The substances 
containing lead should, whenever practicable, be worked up in a 



nt 

1 



• The eyes may suffer from exposure to vapours containing lead, which 
irritate the cornea and cause dejiositions of lead upon it. (Bei.louard, 
KiraiiU professiontlle. Archives O'Ophth., 18B2, p. 1.) 



PREVENTION OF LEAD-POISONING. IO3 

moist state (with water or oil). The workmen's room should be 
veiy well ventilated. The floor should be frequently watered 
and a fine artificial rain should be fi-equently introduced in order 
to beat down the dust Particular apparatus is required in order 
to conduct vapours containing lead to the outer air. A res- 
pirator for mouth and nose, and even a complete mask is 
sometimes needed for the protection of the face and respiratory 
organs. The hands, if needful, may be covered with gloves. 
Meals should not be taken in the work-rooms. Before 
every meal the workman should rinse out his mouth, and 
thoroughly cleanse hands and face. For this latter purpose 
Layet recommends black soap or a weak solution of sulphuric 
acid. The same cleansing process should be adopted when the 
workman leaves the manufactory, and he should also change 
his clothes. Warm baths (especially sulphur baths) should be 
erected by his employers for the use of the workman. Work- 
men employed in the most dangerous parts of the work should 
be frequently changed. Every workman, on the first signs of 
lead poisoning, should cease from the work and be treated 
medically. To do this efficaciously the workmen should be 
subjected to regular medical inspection. 



BLENNORRHOIC CONJUNCTIVITIS. 



Part V. 
. Infectious Eye-Diseases. 

These are the blennorrhoic and the diphtheric inflammation J 
of the conjunctiva. It is doubtful if simple catarrh is infectious J 
at all events it has not yet been certainly proved to be so. As itj 
is not as a rule dangerous to vision ue need not occupy c 
selves with it in this place. 



(a) Blennorrhoic Conjunctivitis. 

Chapter I. General Characteristics of the| 
Blennorrhoic Inflammations. 

§ 35. Blennorrhoic conjunctivitis occurs under varioiu 

forms, which differ from one another partly by the rapidity t 

their course, partly by the changes that take place in 

conjunctiva. Conformably to this, we may arrange them asi 

follows : 

I ( Ophthalmia gonorrhoica 

Acute -! , 

I Ophthalmia neonatorum 



r form 



Blennorrhcea ^ 

Chronic -, ^ „ 
[^ i Papillai 

This arrangement, which differs essentially from the ordinary 
classification of diseases of the conjunctiva requires justification. 
This is all the more easy for me, because I have for the above , 
arrangement the authority of VON Arlt. 



As regards the acute forms, all oculists are agreed that 

I ophthalmia gonorrhoica is essentially the same disease as blen- 
borrhcea neonatorum. 
I The blennorrhoic inflammations that run a chronic course 
feay be divided into two forms, according to the anatomical 
■Iterations they set up in the conjunctiva. The first form is 
characterized by this, that in the conjunctiva gelatinoid, sago-Ukc 
granules appear (trachoma granulations). Hence this disease 
has been called conjunctivitis granulosa (synonyms : trachoma, 
ophthalmia ^gyptiaca,* miUtaris, con], folHcularis, Horner). 
This disease sometimes comes on in an acute manner (acute 
granulations). Much more frequently the attendant inflam- 
matory symptoms are slight or altogether absent for a long time, 
so that the trachoma granulations lie beneath an almost pale 
conjunctiva. 

The second form is distinguished by excessive growth of the 
papiils of the tarsal conjunctiva; chronic blcnnorhcea (syno- 
nyms : ophthalmic punilente chrotiique, conj. granulosa ac- 
cording to some who compare the enlarged papilla to fleshy 
granulations, papillary trachoma). This affection is usually ac- 
companied by severe inflammatory symptoms. 

Both these forms, arc, in my opinion, to be regarded as 

varieties of one and the same disease, for the following reasons : 

a. The greater number of cases observed are compound 

forms. This is proved by the most recent anatomical investiga- 



" Opinions differ as to the form of the ophthalmia which attacked 
Napoleon's soldiers in Egypt. See RaehlMANN, v. Grafts Anlnv 
BA XXIX., PI. 2, p. i+t- 



I06 IDENTITY OF CHRONIC OPHTHALMO-BLENNORRHCEAS. 



tions of Mandelstamm and Raehlmann (V, Stellwag's 
trachoma mixtum^ 

b. Both forms are very similar in clinical respects ; they are 
infectious, are distinguished by an uncommonly slow course, and 
in the end lead to cicatricial contraction of the conjunctiva. 

c. Many authors assert that a person affected with one form 
may infect another, who thereupon gets the other form, GoLD- 
ZIEHER observed in the Buda-Pestb Blind Institution ait. 
epidemic which was introduced by a newly admitted boy. He 
had lost his sight from acute blennorrhcea. All the male and 
most of the female pupils got diseased from him. Among them 
were observed all possible forms, from true blennorrhcea to tnH 
granular trachoma, and all intermediate varieties.* PlRlNGER,fi 
in his inoculation experiments obtained from the same infective 
matter in different individuals both forms, in one case even 
on the two eyes of one and the same individual. VON Arlt, 
also, often observed that one form produced the other by- 
infection. This, in conjunction with the above-mentioned 
reasons, led him to consider both forms as one and the same 
disease. Formerly he had considered them as quite different,, 
he was indeed the first who gave a clear description of the 
true granulations, so that this was often called after him 
trachoma Arlti.} Observations extended over many years 
induced him to abandon this artificial distinction. 

Is there an (Etiological connexion between the acute and 



I 



* Heidelbergcr Ophthalmologenvcrsammlung, 1881, p. 37. 

t Die Blennorrhoe im Mcjischenauge, Grazj 1841. 

I Arlt, Die Krankheiten des Auges, Prag, 1854, Bd. I,, p. loO. 



iETIOLOGY OF BLENNORRHOIC OPHTHALMIA, IO7 



chronic forms of blennorrhoea ? It does not admit of a doubt 
that chronic blennorrhoea often remains after acute blennorrhoea. 
This is frequently, but not always the case ; most cases of 
chronic blennorrhoea indeed arise without such acute preliminary 
stage. The typical conj. granulosa does not occur as the final 
stage of acute blennorrhoea, and yet vON Arlt has observed the 
occurrence of trachoma granulations also in chronic blennorhoea 
which had been caused by infection with gonorrhoeal matter.* 
SATTLERt relates the following case: a mother, who was 
suffering from slight leucorrhoea had a child, which was affected 
with acute blennorrhoea of a mild character. The child infected 
the mother, who got true trachoma, although she resided in a 
locality free from trachoma, and hence could not have been 
infected in any other way. A similar case was that of Gold- 
ZIEHER above alluded to. 

There is therefore no doubt that infection from acute blen- 
norrhoea may cause on the one hand chronic blennorrhoea, 
and on the other conj. granulosa. This again proves the 
connexion between both chronic forms and their relation to 
acute blennorrhoea. It is therefore possible that all blennorrhoic 
inflammations of the conjunctiva may originally be due to in- 
fection from the genitals. In the case of acute blennorrhoea this 
would generally be direct, of chronic blennorrhoea indirect. For 
as acute blennorrhoea may pass into chronic, the latter by being 



* Arlt, ibid, p. 113. 

t Heidelberger OphthcUmologenversamnilung^ 1881, p. 27. 



lOS MODE OF INFECTION. 

conveyed to another may produce at once the chronic form ] 
which then runs its course as such* 

At ail events I firmly believe in the identity of the tww 
chronic forms of blennorrhoic ophthalmia. And this I do alll 
the more, because, as regards the prophylaxis, no difference can I 
be made between the two. I shall employ the term trachoma I 
for both, for the simple reason that it is the shortest. 

§36. All the blennorrhoic inflammations of the conjunctival 
have this in common, that they are not autochthonous, but are I 
always caused by infection. The infectious matter is derived 
from a diseased vagina, from a urethra affected with gonorrhcea, 
or from a blennorrhoic eye. As regards the infection the J 
following points are to be noted : 

1. Tht conveyance of the ntatter can take place directly, e^.A 
by the spurting of the matter into the eye of the physiciai 
during his examination. Much more frequently, however, theil 
conveyance of the secretion takes place indirectly, by thel 
finger, by towels or other linen, by sponges, &c. 

2, The danger of infection is greater the more copious and 1 
puriform the secretion is. A virulent leucorrhosa of a purulent A 
character in the mother constitutes a much greater danger foi 



* NeisseR was Ihe first 10 discover in the discharges of gonorrhcea and 
of acute blennorrhcea a special micrococcus (ganococcus). Sattler and 
Leber found this micrococcus in the secretion of trachomatous ophthahnia, 
■ the former found it also in the interior of the trachoma granulations. Inoc- 
ulations with pure cultivations of these organisms have produced the 
characteristic trachomatous conjunctivitis. If these observations are con- 
firmed, they will go far to prove the identity of origin of the acute and chronic 
forms of blennorrhcea. 



piringer's experiments. 109 

the child than a simple vaginal catarrh with mucous discharge. 
The acute blennorrhoeas are, as regards infection, much more 
dangerous than the chronic,, and these latter again more 
dangerous the greater the inflammation and secretion that 
accompanies them. 

Piringer performed experiments by introducing blennor- 
rhoic matter directly into human eyes, which had a healthy 
conjunctiva (but were otherwise mostly blind).* He made in 
all 84 inoculations on 49 persons, and these inoculations were 
made with the gonorrhoeal discharge from the genitals as well as 
with that of blennorrhoic eyes. He found that the secretion of 
an acute blennorrhoea of a mild character, at the very commence- 
ment when it is as clear as water, does not convey infection, 
and the same is the case with the limpid secretion of many 
chronic blennorrhoeas. On the other hand infection ensues 
certainly and violently when we employ the purulent secretion 
of an acute or chronic blennorrhoea for our inoculations. 

3. Tlie severity and rapidity with which the infected eye 
becomes affected, depend on two circumstances : the origin of 
the secretion and the amount and freshness of it. If an eye 
with acute blennorrhoea infects another eye, the latter develops^ 
as a rule, also acute blennorrhoea, which may even appear in 
from six to eight hours. If the infecting eye is suffering from 



♦ [This is not quite correct. Piringer's subjects were affected with 
pannus, which is generally accompanied by a granular condition of the con- 
junctiva. The numbers he inoculated were 61 eyes in 33 individuals. I 
believe I was the first to practise this method in this country. I published a 
successful case in \b& Edin, Month, Jour, of Med. Soc, May, 1844. — R.E.D.] 



no PIRINGER'S EXPERIMENTS. 

trachoma, the infected eye as a rule gets the same disease. The 
period of inoculation is then longer, from 72 hours (PiRlNGER) 
to 7 days (Sattler) and perhaps still longer. The disease 
comes on often so unobservedly that the infected person does 
not notice it until much later. 

Perfectly fresh secretion is the most efficacious. If dried 
upon linen rags it retains its infective power for about 36 hours ; 
when it is preserved like vaccine matter, for about 60 hours. 
Within this limit it is still efficacious, but causes a milder inflam- 
mation than if it were fresh. Thus the secretion of a very severe 
blennorrhoea, if it has been dried for some days, only produces a 
slight blennorrhoea, moreover it takes a longer time to make its 
appearance (in one case eight days). — Dilution with water also 
weakens or entirely destroys the efficacy of the secretion. But 
the secretion of a vioknt acute blennorrhoea requires to be diluted 
more than 100 times in order to become inocuous (PiRlNGER). 

4. The facility and severity with which the infection acts, 
depends also on the cojtdition of tJie infected eye, A catarrhal 
condition of the conjunctiva seems to make it more sensitive to 
the action of the infecting matter. The conjunctiva of healthy 
eyes does not, as PiRlNGER found, always react in the same way 
to the blennorrhoic poison. 

Can the infection also take place through the air ? This may 
occur, as we may imagine, if the dried secretion is distributed 
in dust-form through the air of the room and thus comes in 
contact with the healthy eye. Whether this ever actually takes 
place is not yet satisfactorily determined. 



BLENNORRHCEA NEONATORUM. Ill 

Chapter II. Blennorrhoea Neonatorum. 

Infection takes place in the great majority of cases of 
blennorrhoea neonatorum by the vaginal secretion of the mother, 
in a few cases also by inoculation from one infant to another. 

§ 37. Infection by the vaginal secretion of the mother usually 
occurs during or rather immediately after birth. The child 
passes through the mother's genital passages with closed eyes. 
Hence during the passage of the infant's head through the 
vagina, the vaginal secretion can only penetrate into the con- 
junctival sack with difficulty and in small quantity. But the 
secretion remains attached to the eyelashes and edges of the 
lids. It can enter the conjunctival sack as soon as the infant 
opens its eyes and winks repeatedly. — Infection incurred 
during the passage of the head through the vagina might take 
place if the labour were very protracted so that the head 
remained a long time in the vagina, or if the forceps were 
applied to the head. Under these circumstances, as Haussmann* 
observes, the soft parts of the face may be displaced, and thus 
a direct opening of the lids affected. Perhaps this is the reason 
why blennorrhoea more frequently attacks boys than girls 
(Haussmann), because the bigger heads of the former pass 
more slowly through the vagina, and are more firmly pressed 
on by its walls. 

Cases have been recorded where the blennorrhoea broke out 
immediately after birth, or was actually present during the 



* Haussmann, Die Bindehaut-Infection der Neugebomen^ Stuttgart, 
1882. Many of the following data are taken from this monograph. 



birth. In one case, indeed, the infant when bora showed 
perforation of both corneze as a consequence of blennorrhoea. 
In these cases, we must conclude that the infection took 
place inlra utero. HaussmanN thought that the infection 
of the child in such cases was caused by the accoucheur duringf;] 
his examination introducing the vaginal secretion on his finger' 
into the membranes or directly on the child's face. This latter 
is possible in face presentations. 

The blennorrhcea of new-born infants is not caused by the 
secretion of a virulent vaginal catarrh only; it may be produced 
by the secretion of a simple catarrh of the vagina. This is 
admitted by most authors, It is, of course, not always easy to 
pronounce with certainty on the true character of a vaginal 
catarrh in the practice of a lying-in hospital, but this is frequently 
possible in private practice. Almost every oculist has met with 
cases in which the infants got blennorrhea from an undoubtedly 
mild fluor albus. Opportunities for making such observations 
are constantly occurring, as leucorrhcea is one of the most 
ordinary accompaniments of pregnancy.* 

When the infection takes place during labour, the disc; 
appears on the second to the fifth dayf. The different duration. 
of the period of incubation depends on the character of 
secretion, and the quantity introduced into the eye. 



I 



ons 

lOSt^J 

the- ^ 



• Hau.SSMANN met with catarrh with mucous or purulent discharge 249 
times among 250 pregnant women of the lower classes, and 30 times among 
50 pregnant women in private practice. Charrier saw 72 cases of vaginal 
catarrh among 100 pregnant women. 

t Crede (Archiv f. Gyndkologie, Bd. XVIII., p. 367) asserts that the 
children infected during labour, show the disease mostly on the second or 
third day after birth, never after the fifth day. 



INFECTION AFTER BIRTH. 1 13 

§ 38. When the ophthalmia comes on later than the fifth 
day, we must conclude that the infection occurred after birth. 
In this case it was caused by the lochial secretion, which was 
introduced into the infant's eye by the mother or nurse by 
means of a dirty finger, by the linen, sponge, &c. But this 
seems only to take place from the lochial secretion of women 
suffering from leucorrhoea. At least the inoculations made by 
ZWEIFEL* with the lochial discharge of perfectly healthy women 
had no effect on the eyes of new-born infants. 

The infection of an eye by another eye suffering from blen- 
norrhcea often takes place. — In all cases where the two eyes 
of an infant are not simultaneously attacked, but where one 
gets the disease two or more days after the other, we may 
take for granted that the second eye was infected by the first. 
So also the conveyance of the disease from one infant to 
another frequently occurs. This happens particularly in the 
foundling and lying-in institutions, in consequence of the 
carelessness of the nurses. Many children are infected in this 
manner. Of 4140 blennorrhoic children (some inmates of a 
Parisian creche, some belonging to the Petersburg Foundling 
Institute) 1622, consequently 39° /q, first got the disease in an 
asylum where they were infected by other children.t In the 
Vienna Foundling hospital there were admitted from 1854 to 
1866, 130,104 children of whom 5,6 16 were affected with blen- 
norrhcea. Of these 1,41 3=25°/^, first got the disease in the 
Foundling Hospital. 

* Archivf, Gynakologte, Bd. XXII., p. 325. 

t Report ^DOLBEAU, Frobehus, Dobb, see also Haussmann. 

8 



114 OTHER CAUSES OF BLENNORRHCEA. 

Are there any other causes of blennorrhoea neonatorum ? 

In former times many attributed the production of blen- 
norrhoea to intense light, to a chill, to mechanical injuries 
received by the eye during birth, to icterus, &c. ; nowadays this 
view has but few supporters. Haussmann is of opinion that 
the infection of the infant's eye can take place by secretions that 
have nothing to do with the mother's genitals ; purulent secre- 
tion from an excoriated nipple of the mother, or from a 
suppurating navel of the child, from the contents of a pemphigus 
blister which may have got into the eye, raw meat applied 
to the eye, &c. I believe that all these things are capable 
of causing catarrh of the conjunctiva, but not blennorrhoea. 
In blennorrhoea of the lachrymal sack, in many cases of caries of 
the orbit often much pus, and even decomposed pus may enter 
the eye, the virulent character of which is shown by its attacking 
the cornea and producing abscess of the cornea. But blen- 
norrhoea as a consequence of this is never observed. Nor is it 
ever caused by matter from an abscess when opened spurting 
into the doctor's eye, or when decomposed fluid from a dead body 
gets into the eye of the anatomist. Sattler has settled this by 
experiment ; he introduced putrid flesh, putrid blood and pure 
cultivations of various putrefactive fungi into the human con- 
junctiva without obtaining any bad effect. We must, therefore, 
conclude that the conjunctival blennorrhoea owes its origin to a 
fungus, which finds a suitable soil for its development only on the 
genital mucous membrane and the conjunctiva of human beings. 

The conjunctivitis of new-born infants therefore has its 
source in the vaginal secretion of the mother. At the same 



FREQUENCY OF BLENNORRHCEA NEONATORUM. II5 

time we cannot doubt that many still unknown circumstances, 
especially facilitate the infection at certain times ; regular 
epidemics of conjunctival blennorrhoea are sometimes seen in 
lying-in and foundling hospitals. The season of the year has 
not as yet been positively ascertained to have any influence on 
its production. 

§ 39. Frequency of blennorrhoea neoiiatoruvu — We possess no 
statistics relative to the occurrence of blennorrhoea in general, 
only relative to its frequency in certain lying-in and foundling 
hospitals. The figures given in these reports vary very much, 
which — besides other causes — depends on different principles of 
calculation. 

The ophthalmias which attack new-born infants may be 
divided into milder and severer cases ; the former are of 
catarrhal, the latter of blennorrhoic character. There is no 
doubt that a great number of the catarrhal cases are attributable 
to infection. This is proved by the observ^ation that under a 
suitable prophylactic treatment the number of cases, not only of 
blennorrhoea but also of catarrh is greatly diminished. Hence 
we must conclude that in the mild cases either the vaginal 
secretion was less infectious, or that very little of it entered the 
eye. 

The various observers sometimes include these catarrhal 
cases in their calculations, sometimes they omit them, but 
without always telling us which plan they adopt in their reports. 
Hence it comes, for example, that in the University Lying-in 
Hospital in Berlin the percentage of blennorrhoic children to 
the total of the infants in a scries of years, varies between i °/^ 



ii6 



STATISTICS OF BLENNORRHOEA NEONATORUM. 



and 8 %, whereas on the other hand in the Berlin Charit6 
Hospital the blennorrhoeas amount to between 7 and 21 °/^. 
In the subjoined table I give a resuvtd of the data of a number of 
lying-in and foundling hospitals, which will be found in extenso 
in Haussmann : 



I. Lying-in Hospitals. 



Hospital 



Berlin University Lying- 

„ Charity Hospital 
Breslau 
Dresden 
Halle 
Leipzic 
Munich* 
Stuttgart 
Vienna I. Klinik 

„ 11. 
Petersburg 
Stockholm 



in Hospital 



Number of affected 
childreo per cent. 



» 



Years. 
1829 69 1.07 8.3 



1817—79 7.4 —21.3 

1827—77 7.0 —18.5 

1826—75 2.2 —25.3 

1840 — 79 2.8 — 21.7 

1849—79 7-6 —13.6 

1860—81 0.8 — 5.2 

1828 — 79 5.8 — 20.9 

1857 — 64 0.84 — 2.3 

1857 — 64 0.6 — 1.6 

1845—54 1.2 — 1.4 



— 2.9 — 7.9 



II. Foundling Hospitals, 



Prague 1865 — 68 8.6 — 13.0 

Vienna ... ... ... ... ... 1856 — 66 4.31 

Petersburg 1830 — 78 5.9 — lo.o 

Of the blennorrhoic children of the foundling hospitals, 
about one-fourth to one-third were first taken ill by infection 
from other children. 



♦ V. Hecker, Archivf, Gyndkologie^ Bd. XX., p. 387. 



DIFFERENT DEGREES OF BLENNORRHCEA NEONATORUM. 1 17 

The records respecting cases of blennorrhoea occurring in 
l3nng-in hospitals do not allow us to come to any precise conclu- 
sions as to the frequency of blennorhoea outside these establish- 
ments. It is probable that they occur among the better classes 
seldomer, among the lower classes oftener than in lying-in 
hospitals. Cleanliness is less attended to among the poor 
people (and the linen at their disposal scantier) than in a well 
ordered lying-in hospital. — Nor do the reports of ophthalmic 
hospitals enable us to form an opinion respecting the frequency 
of blennorrhoea among the population ; not even respecting the 
proportion of blennorrhoea to other eye diseases. Blennorrhoea 
is very frequently neglected by parents and midwives, and as a 
rule it is only the severer cases that are brought to the doctor. 
HiRSCHBERG met with only 1.46 °l^ of blennorrhoea neonatorum 
among 21^0 eye patients. 

§ 40. Dangers of blennorrhma, — I have stated above that 
besides the severe cases many slight cases also occur, which 
bear the character of simple catarrh of the conjunctiva. 

KOENIGSTEIN* found that of 1,092 children in the II. Lying- 
in Hospital in Vienna, 4.76 °/o were affected with blennorrhoea, 
14.5 7o ^^^h catarrh. Some of the reports of the Dresden 
Lying-in Hospital also distinguish between severe and slight 
cases. Of 690 cases of blennorrhoea 360 were severe, 330 slight. 
The difference of the data is explained by the different meanings 
attached to the terms severe and slight. It is impossible to 
draw a hard and fast line between the two, nor is it needful to 

* Archtvf, Kinderheilkundey Bd. Ill,, 1882. 



ii8 



DANGERS OF BLENNORRHGEA NEONATORUM. 



do SO. On the other hand it is important to know how often 
the cornea will be implicated and the sight thereby imperilled. 
Unfortunately there are but few records which giye information 
on this point. I have subjoined all that I have been able to 
collect bearing on the subject : 



Hospital. 



Cases of 

Bleo- 
norrfaoca. 



Opacity of 
Cornea. 



Blindness 
of one eye. 



Blindness 

of both 

eyes. 



Per cent. 

of injured 

eyes. 



Berlin Charity 

Munich Lying-in Hospital* 

Dresden 

Stuttgart 

Vienna Foundling Hospital 

Prague 



» 



>i 



» 



j> 



213 


2 


2 


? 


123 


I 


2 


I 


1378 


38 


IS 


4 


538 


13 


12 


I 


1347 


112 


171 


42 


300 


105 


32 


? 



1.9 

2.4 

3.8 

4.6 

21.0 
45.7 



To this table I have to make the following remarks : In the 
reports the words used are often " opacity of the cornea " or " dim- 
ness of the cornea " ; all these I have placed under the heading : 
" opacity of the cornea." But as it is not said to what extent 
this dimness of the cornea went in the several cases, it is quite 
possible that many of the cases of total blindness should come 
under this heading. The difference between lying-in hospitals 
and foundling hospitals is very striking, the latter showing a so 
much greater number of blind cases. In most lying-in estab- 
lishments the women, when they are in good health, are dis- 
missed in from eight to ten days after delivery, even thougH- 



* V. Hecker, Archivf. GynHkologie^ Bd. XX., p. 388, 



DANGERS OF BLENNORRHCEA NEONATORUM, II9 

their children may have bad eyes. As a rule nothing is known 
about the future state of the child ; so that it is possible that 
many children become blind after leaving the hospital. But the 
high proportion of blindness in the foundling hospitals is owing 
to this, that most of the blennorrhoic children have the 
blennorrhoea when admitted, and that not unfrequently in a 
very neglected state, where the cornea is already implicated. 
In such cases the treatment often comes too late. Hence the 
proportion of cases of blindness in foundling hospitals approxi- 
mates to that in ophthalmic hospitals. In the latter also, besides 
recent cases many far advanced cases come under treatment. 
I subjoin a list of these cases from the reports of various 
observers : 

Author. Number of Affections Blindness of Per cent, of 

cases observed, of cornea, both eyes. injured eyes. 

HORNER* 108 43 O 39.8 

HlRSCHBERGf 200 55 6 27.5 

ScholerJ 156 43 ? 27.5 

Heymann§ 139 25 ? 18.0 

Emrys Jonesii ... 420 72 16 1 7. 1 

These figures make blennorrhoea appear to be more dan- 
gerous than it is in reality, because oculists see more severe 
and neglected cases than mild ones. Still these figures accord 



♦ Handbuch der Kinderkrankheiten^ herausgegeben von Gerhardt, 
Bd. v., Pt II., p. 262. 

t Beitriige zur praktischen Augenheilkunde^ 1876, p. 6. 

t JaJiresbericht^ 1880, p. 7. 

§ Prager Vierteljahresschrift^ i860, II., p. 70. 

II Manchester Medical Society^ February, 1881. 



L 



• •• 



• •• 



Number of 

cases of 

blennorrhoea. 


Blindness 

of both 

eyes. 


Percent' 
age. 


1347 


42 


3.1 


200 


6 


3.0 


420 


16 


3-8 



120 BLINDNESS FROM BLENNORRHCEA NEONATORUM. 

very well with those furnished by the foundling hospitals as 
regards the number of blindness of both eyes : — 

Vienna Foundling Hospital 

HiRSCHBERG 

Emrys Jones 

Horner is an exception, for he had not a single case of 
blindness among 108 cases. 

There is no doubt that every year a great many new-bom 
infants become affected with blennorrhoea, and owing to this a 
certain number of them lose their sight 

It is not possible to determine the exact number of the con- 
tingent which those who have lost their sight by blennorrhoea 
contribute to the total number of the blind. The data on' this 
subject are no doubt numerous, but too divergent to allow us to 
draw an accurate conclusion. This divergence of the data is 
caused by two things : The differences of the material investi- 
gated and the various frequency of blennorrhoea in different 
countries. 

The material investigated is of three kinds, i. The pupils 
of blind asylums ; 2. The cases of blindness applying to ophthal- 
mic hospitals ; 3. The inhabitants of a whole province. I will 
give examples from each of these three categories. 

I. — Blind Asylums, 



Percentage of blenn. 
blindness. 



Reinhard... 



' Germany, Austria, 
Denmark, Holland 

V/LAISSE ... • • • X ariS ••• ... ••• 'T^ 



} 



BLINDNESS FROM BLENNORRHCEA NEONATORUM. 121 



Magnus 
Katz 



•• • 



Breslau ... 
Berlin 



II. — Eye Hospitals and Dispensaries. 

Magnus 9 German hospitals 

COHN Breslau 

Daumas Paris 

BOURJOT St. Hilaire Paris 



III. — Total Population. 



Brunswick 
Nassau 



34 


41 


10.8 


ii.i 


69.3 


27 


28 


13 



What is the true proportion of blindness caused by blen- 
horrhcea to blindness in general? The blind asylums make 
this proportion appear too high, because they admit principally 
young blind persons, among whom the blennorrhoic are propor- 
tionally frequent. In the eye hospitals such blind cases come 
less frequently than others, because the most of them regard the 
misfortune they have had from their infancy as irremmediable ; 
hence probably the reason why COHN and MAGNUS have found 
such a small percentage. Then again, the examinations of the 
blind of an entire country are as yet too few and too superficially 
carried out to allow us to come to precise conclusions. Besides, 
blennorrhcea does not everywhere prevail to the same extent ; its 
occurrence depends on the one hand on the prevalence of vaginal 
catarrh, on the other hand on the degree of civilization and 
thence resulting cleanliness of the people. 

§ 41. The prophylaxis of blennorrhea neonatorum is one of 
the most important, and at the same time satisfactory, problems of 



122 PROPHYLAXIS OF BLENNORRHCEA NEONATORUM. 

hygiene. Appropriate treatment may, in the great majority 
of cases prevent infection. If in spite of all precautions the 
disease should occur, we possess such reliable modes of treatment 
that we may with tolerable certainty prevent blindness. 

We have now to occupy ourselves with the prophylaxis 
against infection, and with the treatment of the blennorrhoea 
itself 

(A.) Prophylaxis of BlennorrhcBa. 

Protection against infection is a natural consequence of the 
knowledge that blennorrhoea depends on infection. At the 
beginning of this century (1807), GiBSON indicated clearly and 
rightly the fundamental principles of the prophylaxis in the 
following maxims : 

1. The leucorrhoea of the mother ought, if possible, to be 
cured during the pregnancy. 

2. When this has not been done, the noxious secretion ought 
to be removed from the vagina during delivery. 

3. The infant's eyes ought, immediately after the birth, to be 
cleansed with a fluid which either removes the noxious matter, 
or is able to prevent its injurious effects. 

The requirements of prophylaxis could not be more precisely 
enunciated at the present day. All the more wonderful is it that 
these efforts to prevent blennorrhoea were afterwards completely 
forgotten, although the doctrine of the infectious nature of the 
disease became more and 'more established. It is only in quit^^ 
recent times that they were again adopted. The first serioi:3i^-^ 
commencement in this direction was made in Basel. BlSCHOFE^^ J 

* Horner, Gerhardfs Handbuch der KinderkrankheiteUy Bd. V., p. a- "^ 



DISINFECTION OF MOTHER. 1 25 

in 1875, carried out in a methodical manner the disinfection of 
the vagina in the Basel Lying-in Hospital, with a solution of 
carbolic acid, and at the same time washed the eyes with 
salicylic acid. SCHIESS of Basel, published an essay in 1876, in 
which he directed the midwife to cleanse the eyes of the infant 
immediately after birth with a disinfectant. Since then, in 
many institutions similar trials have been made and reported 
on. 

The prophylaxis must endeavour to prevent infection, both 
during deliver}', and after birth. 

I. Infection During Bir*th. 

§ 42. In order to hinder this, two methods have been) 
proposed : The disinfection of the maternal passages and the 
disinfection of the eyes of the new-born infant. 

As regards the mother, it is especially desirable to cure 
during pregnancy any vaginal catarrh that may be present,, 
particularly if it be attended by a purulent secretion. If 
this has not been done, the disinfection of the vagina must be 
performed during delivery. The discharge of the liquor amnii 
effects a washing out of the vagina. But some secretion may 
still remain among the folds of the mucous membrane,, 
and also on the external genitals. Should the labour be slow, 

as is generally the case with primaparcBy after the membranes 

have given way there is plenty of time for the collection of 

fresh secretion in the vagina. 

On this account Crede, in his first publication, lays great 

stress on the disinfection of the vagina, whilst at the same time 



124 DISINFECTION OF THE EYES. 



he cleanses the eyes of the infant with a solution of borax. 

Haussmann also is strongly in favour of this method. BiSCHOFF, 

as already mentioned, introduced it into his hospital since 

1875. In Austria, the mid wives are required to disinfect the 

vagina before delivery. Whether the disinfection of the 

maternal passages will alone suffice to prevent blennorrhoea, I 

* 
am unable to prove by statistics, for disinfection of the eyes is 

always performed at the same time. 

At the present time all are agreed that the chief thing is 
the disinfection of the infant's eyes. The infecting secretion, as 
a rule, obtains access to the infant's eyes after birth. It hangs 
about the borders of the eyelids and eyelashes, and gets into the 
•conjunctival sack when the child opens its eyes and winks 
repeatedly. Infection of the infant can be prevented by appro- 
priate cleansing of the eyes. — But is a really efficacious disinfec- 
tion possible if in spite of this some secretion penetrates into the 
the conjunctival sack? PiRiNGER's experiments answer this 
question in the affirmative. He found that blennorrhoic 
matter introduced into the conjunctival sack produces no effect, 
if very soon afterwards (at latest three minutes) the conjunctiva 
be carefully rinsed out with water, and then cold compresses 
applied for some hours. 

The different methods proposed for the treatment of the eyes 
of newborn infants are divisible into the three following 
groups : — 

{a.) Simple cleansing of the eyes. — Abegg* recommends careful 



Archivf, Gynakologie^ Bd. XVII., p. 502. 



DISINFECTION OF THE EYES. 12? 

washing out of the eyes with pure water ; since doing so he has 
only 3 °/^ of blennorrhoeas. 

SCHIRMER thinks that the infection of the eyes is generally 
caused by the bath water, and hence he directs that at first the 
head should only be wiped with a dry towel ; the face should 
not be washed in a basin till next day. By following this plan 
he had no case of blennorrhoea in fifty births. 

{b,) Cleansing the eyes with disinfecting fluids. Most of the 
disinfectants used in surgery have been recommended. FlEUZAL 
IS in favour of weak solutions which shall not irritate the eyes, 
thus carbolic acid in the proportion of i to 250, but he enjoins 
frequent ablution with it, and if the eyelids are swollen he 
advises the application of cold compresses.* 

CreD]^ in his first trials used a solution of borax (i to 60), 
but was not quite satisfied with it. BiSCHOFF employs a solu- 
tion of salicylic acid, whilst SCHMlDT-RlMPLER gives the 
preference to chlorine water. But far the greater number made 
their experiments with carbolic acid ; this has the advantage of 
being at hand in all hospitals, and even midwives are bound to 
carry it about with them. Haussmann recommends a i °/q 
solution of it ; OllLSHAUSEN employs it in a 2 °/^ solution (not 
in I °/o 3.S erroneously stated in his publication) ; BUNGE and 
Macdonald the same. Graefe advises that the eyelids should 
be everted when the solution is applied. 

c. Instillation of argenti nitras, — Crede having obtained 
no satisfactory results from the borax solution proposed the 

• Congrh iVhygilne de Genh'c, T. I., p. 233. 



126 RESULTS OF DISINFECTION. 

following plan. He first cleansed the eyes carefully with salicylic 
acid (2 to 100) and put into the conjunctival sack one drop of 
nitrate of silver solution, and then laid compresses with salicylic 
acid (2 to 100) on the eyes for twenty-four hours. Afterwards 
he altered this procedure by omitting the compresses of salicylic 
acid, and merely washed the eyes with water, and then dropped 
into them the nitrate of silver solution. KOENIGSTEIN, Felsen- 
REICH and Bayer adopted Crede's last method. 

§ 43. The best proof of the value of this procedure is the 
resitlt. Before going into the examination of the advantages 
and disadvantages of the several methods, I will give a collective 
view of the results obtained by them. I have endeavoured to 
present not merely the percentages of blennorrhcea, but also the 
absolute numbers of the infants observed. The larger these 
figures are the greater right have we to regard the results as 
decisive. 

A comparison of the data given in the table, in order to 
form a judgment relative to the value of different modes of 
precedure gives the following : Simple cleansing of the eyes 
with water, diminishes to some extent the frequency of the 
occurrence of blennorrhcea. Thus BiSCHOFF, before employing 
his salicylic ablutions, merely by observing great cleanliness and 
care in the nursing, brought down the proportion of blen- 
norrhoeas from 5.6°/^ to 3.S°/o. Cleansing the eyes and con- 
junctival sack with carbolic solution gives still better results ; 
and by this means KOENIGSTEIN reduced the blennorrhceas to 
i.4°/q. In each of these methods a great deal depends on the 
period when, and the care with which the cleansing is performed. 



RESULTS OF DISINFECTION. 



127 







V 
















M 
















1 

































fO 





vO 


00 


VO 


■* 


■* 





«^ 


■* 


ON 





m 






u 






• 


a 


• 


• 


• 


•*-> 




N4 


• 


• 












w 


QO 


fO 




M 


• 





• 




M 


M 








^ 































^i 
































0^ 
















N 
















S ^ 


1 







N 


NO 


M 


H4 





ON 


M 


00 


M 


1 






s s 


1 






M 




M 


N 


•*•* 






to 


N 


1 






U 
















H4 
















^■^ 4j 






























































.J9 


PQ 






























II 







1 




:g 


QO 


M 
^ 


v8 




to 





g 


8 






>\ 






1 


M 


M 




10 


M 


n 


«^ 


Q 


M 


CO 


I 


f 

Pi 


55^ 














M 


»H 


M 




CO 


N 




, 
































to 




• 


• 
• 


• 


<U 








• 
• 


• 


• 


• 


* 
• 


• • 


' 


.S 

1 




• 




• 


> 

a 
to 








• 


• 


• 


• 


• 


• • 


1 


a 


• 

•3 


• 

u 



• 
• 

• 
• 
• 


• 
• 
• 

• 
• 


0) 


•^ 

^ 

2 
^ 

^ 


0^ 


•^ 
M 

#» 
•« 


• 
• 




• 
• 


• 
• 
• 




•B 

a. 



• 9 

• • 

• • 


1 




1 

■a 


■4-1 








'0 








1 

(A 


•s 
«« 


#« 
#« 


9\ 


M 
#« 


:: - 






p 


■*^ 


t./) 




(A 


M 


•% 


#« 


^-l 
















(^ 


to 
.9 

§ 


73 


u 


1 


M 


M 


•\ 









0^ 


M 
«« 










<u 


b 


CO 





^ 


•^ 


^ 





«« 


0^ 


•^ 


0^ 


A M 








U 


Q 







M 








«« 


9\ 


«% 


9S 


«« •> 












NO 


tn 




ro 


00 


00 






CO 




VO 

1^ ro 




.a 








• 

10 






• 


• 


• 








• 




• • 


'1 ^^ 






























1 -s 


cj 




























1 & 


*» 8 




























J s 


2I 








2^ 




N 


M 


^ 






N 




VO 


1 Hi 


P 




1 




NO 


1 


ON 


to 


•>4 


1 


1 


QO 




to 


J ^ 


ai 




























vpa* 






























1 3 


.0 




























"S . 




























1/ <s 


«€ 













VO 


W 


«^ 






t^ 




^ 

M 


1 ^ 


J5 c 
6*5 








to 




VO 


8" 


ON 
00 






00 
00 




a c 












M 


M 


w 






M 




»H 




*- 




























■ 


- • 1 


































m 
m 
• 


• 


• 
• 
• 


• 
• 
• 


• 
• 
• 


• 
• 
• 


• 
• 
• 


■ 
• 


• 
• 


• 
• 


• 
• 
• 


m 


++ : 
++ • 






























Z 


n s 




• 
• 

• 

s 

PQ 




++ 


tli 

:3 






1— • 


• 
• 

* 
* 

Q 

04 




C5 


It 



I-I 






CO 

CO • 








u 

(A 


«% 
M 




:0 


to 

C 

:0 






#« 


(O U 

CO >4 

t3 < 




iP> 




< 


CO 


pq 







M 


« 


U 


t^ 


M 


(z< 




P< « 



!^ ^ ^ 



QO 



00 
00 

i-H ^"^ 

to ^ 

:§ 5 
^ 1 

§ ^ 

I 

ro 
ro 60* 

J* VO 



ti 



N 



►^ Ph ►^ 












Q 

< 
X 

Ui 

O 



« ^ 

§8 . 

I— I S> 

1-4 ;s 

. -^ 

S « 



is > 

CO CJ) 



§ 



td 

* I 



X 
X 
X 

•^ tOrrt 

^ ^« 

^ 5 •!! 

ro «<e 

. 00 :« 

"^^^^ 

- 1 -J 
>^ ? 1 

^ ^ ^ 






n 



128 COMPARISON OF DISINFECTIVE METHODS. 

When Olshausen performed the disinfection of the eyes with 
carbolic acid after severing the navel-string of the infant, he had 
8.8°/^ of blennorrhceas ; afterwards he disinfected the eyes as soon 
as the head was born, and thereby reduced the blennorrhceas to 
3.6°/^,. When the disinfection is left to the midwife, experience in 
this manipulation has much to do with its success. Hence it is 
that in the different lying-in hospitals the proportions are the 
more favourable the longer the practice has been employed. 
Felsenreich in his first period of observation (of Credj^'S- 
method) had i.93°/o, in the second period only 1.0°/^ of blen- 
norrhceas. 

From these data, it is evident that the disinfection of the 
eyes of new-born infants constitutes a very powerful prophylactic 
means against blennorrhcea, provided the disinfection is care- 
fully performed and as soon as possible after birth. It ought to 
be practised on all infants, even on those whose mothers have no 
vaginal discharge. Which is the disinfectant that most deserves- 
to be recommended ? 

Hitherto, only carbolic acid and nitrate of silver have been. 
employed on a large scale. The carbolic solution ought not ta 
be too weak. A two per cent, solution can be dropped into the 
eye without doing harm, though now and then it causes 
swelling and eczema of the lids (KOENIGSTEIN). As regards 
nitrate of silver, we might think that it would injure the eyes 
still more, but, according to Credit's experience and that of 
his imitators, in most infants no reaction at all follows its use. 
In a few hyperaemia and some secretion from the conjunctiva 
were observed ; which, however, went off spontaneously after 



COMPARISON OF DIFFERENT METHODS. 1 29 



three days at most. The solution employed was a 2% ; a weaker 
solution seems not to be efficacious. At least VON Hecker* in 
the Munich Lying-in Hospital, saw no effect from a one per cent, 
solution. As regards the results obtained from both remedies 
the above table shows that Olshausen with carbolic acid had 
still 3.6°/^ of blennorrhcea, whereas Crede with nitrate of silver 
solution had only o.i°/^,. Since his adoption of this method, 
Cred^ had not more than one or two cases of blennorrhcea 
among 1,600 infants. But in order to draw an accurate conclu- 
sion from these data, we ought to know what each of the ob- 
servers understands and designates as blennorrhcea. Olshausen 
says that under his treatment, the blennorrhoeas that occurred 
were all much milder ; another would perhaps have classed 
them as catarrh. Hence the work of KOENIGSTEIN is of great 
value. He distinguished between blennorrhcea and catarrh, and 
classed them separately. He first observed 1,092 children 
without treating them, in another series of 1,541 children, a i°/^, 
carbolic solution was used ; in a third series of 1,250 children, a 
2°/^ solution of nitrate of silver was employed. All this took 
place in the same hospital with the same attendants, and was 
recorded by the same observer, so that these observations best 
fulfil the requirements of a scientific experiment. KOENIGSTEIN 
came to the following conclusions : 



No treatment 


No. of new- 
born infants. 

1092 . 


Per cent, of 
blennor. 

., 4.76 .. 


Per cent, 
catarrh. 

• I4-S 


of 

... 


Total 
Percentage. 

19.26 


With 


2°/^, carbolic wash 1 541 . 


.. 1.42 .. 


. 6 


• •• 


7.42 


With 


1°/^ silver wash 


1250 . 


,. 0.72 .. 


. 472 


... 


S.44 



* Archivf, GynHkologie^ Bd. XX., p. 386. 

9 



i^o credit's method. 



Krukenberg also instituted comparative trials first with 
carbolic lotion, afterwards with nitrate of silver, but in place of 
employing a solution he used a vaseline ointment containing 2°/^ 
of nitrate of silver (he afterwards abandoned this ointment for 
the solution). He himself performed the disinfection, so that 
we may take for granted that uniform care was bestowed on the 
manipulation. His results are : 

No treatment 7-3°/o 

With 2% carbolic wash i34°/o 

With silver vaseline o.l47o* 

Thus by disinfecting treatment the number of cases of 
-catarrh, as w^ell as of blennorrhcea, is reduced. The nitrate of 
silver solution acts more certainly in this respect than the 
carbolic solution ; as moreover experience has shown that the 
silver solution is not dangerous to the eyes, it deserves to be 
preferred to the carbolic solution. In addition to this the 
method proposed by Crede is exceedingly simple. He first ties 
and cuts the navel string, then has the infants put into a bath 
and their eyes cleansed with water. Then the child is laid down 
and into each eye, slightly opened, a single drop of a two per 
cent, solution of nitrate of silver is introduced by means of a 
small glass rod, that is to say it is allowed to fall on the cornea. 
Nothing else is to be done to the eye. 



♦ Krukenbbrg had 4 blenn. among 703 treated with the above ointment 
therefore actually 0.56°/^. Three of these infants, however, took the disease 
from the seventh to the ninth day, consequently they were undoubtedly in- 
fected after birth. He therefore quite properly eliminates these cases, so 
that only the children in whom the disinfection of their eyes was ineffectual, 
remain. 



DISINFECTION BY ]SilDWIVES. I3I 



As regards the mode of action of the silver solution, I look 
upon it in this case as an antiseptic, the solution causing the 
albumen to coagulate and entering into combination with it. ■ 
The silver solution differs from the carbolic solution in this, that 
it acts not only on the surface but also to some extent on the 
deeper parts. Thus it cauterises the outer layer of epithelial 
cells ; hence if the micro-organisms have already penetrated into 
this layer, they will be reached and destroyed by the silver 
solution. For this reason the action of the silver solution is 
much more certain than that of the carbolic solution. — But it is 
desirable that further comparative trials should be instituted, 
particularly with a solution of corrosive sublimate, which accord- 
ing to the investigations of the German Board of Health displays 
the surest antiseptic action. 

§ 44. The methods described have hitherto been chiefly 

carried out in lying-in hospitals. But are they adapted for 

labours occurring outside lying-in hospitals, and can we trust to 

midwives for their performance ? The prophylaxis of blen- 

norrhoea is more important outside lying-in hospitals than in 

such establishments. In the first place the number of births in 

lying-in hospitals is but a small fraction of the total number of 

births. In the second place blennorrhcea is much less dangerous 

in lying-in hospitals, for in them the children affected with eye 

diseases are immediately subjected to treatment. Among the 

people, on the other hand, blennorrhcea is either neglected or 

aggravated by improper treatment, so that many eyes arc 

thereby destroyed. Therefore the prophylaxis of blennorrhcea 

outside lying-in hospitals is more urgently required than in these 



132 SIMPLE METHOD FOR MIDWIVES. 



establishments. But in the former case it can only be carried out 
by midwives. At present the doctor is never called to a normal 
labour in any well-to-do families,* not to speak of the poor people. 
Quite irrespective of the expense this is never done, because the 
number of medical men in many places is insufficient This is 
still more the case in those countries where the doctors are much 
fewer than in ours, e,g,^ in Sweden, where the midwives are relied 
upon even for the performance of the application of the forceps.-f- 
If we are to leave the disinfection of the eyes to midwives^ 
we must adopt an extremely simple treatment. Above all we 
must know if it be necessary in order to apply the disinfectant 
to evert the lids, as Graefe and others direct ? This certainly 
must not be left to the midwives. They might injure the eyes 
by their rough manipulation, and introduce into the eyes some 
still more infectious substances, in the majority of cases in- 
deed they are unable to evert the lids. The object of everting 
the lids is to bring the disinfecting substance in direct 
contact with the whole surface of the conjunctiva. That 
cannot be done unless the everting manoeuvre exposes the 
upper fold. This is the main part to be disinfected, because 
foreign bodies (and consequently the infecting vaginal mucus) 
arc, as is well-known, readily conveyed into the upper fornix. 
The disinfection of this part of the conjunctiva is effected by 
simple instillation, for the fluid, by the process of winking, is 

* [This of course does not apply to England, where the employment of 
male accoucheurs is the rule, that of midwives the exception. — R.E.D.] 

t In 1878, 381 deliveries with forceps were performed by midwives. 
Irgens, Centralblatt f, Gyndkologie^ 1880, No. 47. 



POPULAR INSTRUCTION ON BLENNORRHCEA. 1 33 



distributed all over the conjunctival sack. Neither Crede nor 
KOENIGSTEIN nor Felsenreich directs the lids to be everted, 
for they allow the midwife to perform the disinfection, and yet 
they have obtained remarkably good results. Therefore it is 
not necessary to evert the lids ; simple instillation of the dis- 
infecting fluid suffices, and this may without danger be left to 
the midwife. 

I do not doubt that on an average the midwife will not carry 
out the operation with the same carefulness as a medical man 
would. Still I am in favour of trusting the midwives to do it, 
for in most labours there is no physician present. Of course the 
midwives must be thoroughly instructed in the operation ; by- 
and-bye I will return to this subject. 

The due carrying out of these rules will be facilitated if the 

public are enlightened with regard to the dangers of blennorhcea 

and the means to be taken in order to ward them off. If that were 

done the parents of the infant would in many cases insist upon the 

necessary care being practised. Popular writings on this subject 

have been published by different authors. Briere, in Havre, 

caused a pamphlet of this character to be given to all persons 

ivho intimated at the mairie the approaching birth of a child. 

FlEUZAL proposed to add an avis aiix parents to the livret de 

fnariage, ROTH, in London, published a fly-leaf about blen- 

Tiorrhcea in the name of the Society for the Prevention of Blind- 

"Hess. As a consequence of these numerous efforts some govern- 

nncnts have already begun to direct their attention to the matter. 

The new Prussian midwife's book* published in 1878, says : 

The midwife should begin by cleansing the eyes, but not with 



134 INFECTION BY BATH AND LOCHIA. 

the bath water " ; it would have been as well to add, " nor with 
the bath sponge." In September, 1880, the French Government 
caused a note to be inserted in the Journal des Communes calling 
general attention to this subject. In December, 1882, the 
Austrian Government issued an edict in which Crede's- 
method was recommended to medical men. The Hungarian 
Government distributed to all the midwives in the country a 
popularly written treatise upon the blennorrhcea of new-bom 
infants. 



Chapter II. Infection after Birth. 

§ 45. At the first bath the dirt adherent to the infant's body 
gets into the water and may, when the face is being washed, get 
into the eyes. SCHIRMER regards this "poison water," as he 
terms it, as the chief danger of infection. I do not think that 
the danger is so great as that ; PiRlNGER's experiments have 
shown that the blennorrhoic secretion loses all its virulence 
when diluted to a certain extent. Nevertheless it is very 
advisable not to use the bath water to wash the face not only on 
the first day but also on the subsequent days, and to employ 
pure water and a separate sponge or linen rag. 

On the days following the birth infection may be conveyed 
by the lochial secretion. In many lying-in hospitals, as also' 
among the poorer classes, the infant has no crib to itself, but lies 
in its mother's bed. In consequence of this, and also of want 
of cleanliness of the linen, fingers, &c., the conveyance of the 
secretion to the eyes is possible. Greater care and cleanliness. 



INFECTION IN LYING-IN AND FOUNDLING HOSPITALS. 1 35 

of the attendants and of the lying-in woman herself is above 
all things requisite. Haussmann proposed to remove the 
lochial secretion as much as possible, syringing the vagina twice 
a day with a two per cent, solution of carbolic acid. Graefe 
advises the instillation into the infant's eyes of a two per cent, 
solution of carbolic acid every twelve hours during the first two 
days after birth. 

In lying-in and foundling hospitals blennorrhoea is often 
communicated from one child to another. Want of cleanliness 
and carelessness in the nursing, the employment of the same 
bath water, of the same sponges and linen for healthy and 
diseased children are to blame for this accident. We must 
therefore insist that each infant has its own utensils. 

In foundling hospitals nurses with blennorrhoea of the vagina 
or eyes should not be employed to suckle the infants, if this 
can be avoided. — Many children brought to foundling estab- 
lishments have the germs of the disease on admission, and it 
bursts forth in a day or two. On this account Haussmann 
advises that all the children on admission should have their 
conjunctival sack disinfected by an instillation of nitrate of 
silver solution. 

Over-crowding is one of the most powerful agents for pro- 
pagating blennorrhoea. Unfortunately many of the large lying- 
in and foundling hospitals are almost always over-crowded. 
When that is the case, all the greater attention to cleanliness 
and ventilation is necessary. The physician should inspect the 
children every day, and in the case of infants with diseased 
eyes should do what is required. This includes, besides the 



136 TREATMENT OF BLENNORRHCEA NEONATORUM 



medical treatment of the blennorrhoea, the isolation of the 
affected children. This is the more important the larger the 
establishment and consequently the greater the difficulty of 
paying attention to every separate case. In Paris Lefort 
carried out this separation with excellent effect. The number 
of infants with eye diseases declined quickly until the disease 
was almost extinguished. 

(B) Treatment of Blennorrhoea. 

§ 46. — By assiduous carrying out of the prophylactic rules 
we shall succeed in keeping down blennorrhoea to a minimum 
in lying-in hospitals, and perhaps also by-and-bye among the 
people ; we shall never be able to suppress it entirely. 
Fortunately, blennorrhoea is very amenable to good treatment ; 
if the treatment is commenced sufficiently early a good issue is 
to be reckoned on almost certainly. Most oculists are agreed 
on this point, so that I may content myself with citing only a 
few data in proof of this assertion. 

Horner had in io,oco cases of eye disease, 108 fresh cases 
of blennorrhoea; all recovered without injury to the sight 
HiRSCHBERG gives an account of 200 cases ; 6 of these came 
with the cornea already destroyed, so they had to be refused 
admission ; of the remaining 194 cases not one single eye was 
lost. In Schweigger's clinic there were 45 2 cases; of these 123 
had already corneal affection, and 43 lost their sight completely. 
The remaining 329 cases which came under treatment before 
the corneal affection was present were all cured without injury 
to the sight. So we may say that a complete cure will b3 



IN ANU OUTSIDE HOSPITALS. 



137 






^^ giv 



ttained in every case where the treatment commences before 
ia implicated. Hence the most important thing is 
Eto bring the cases early under treatment. In lying-in hospitals 
'Where the children are under medical inspection for at least the 
first eight days, this is easy. Hence the proportionately favour- 
able figures in the table given at p. 118 for the eyes blinded by 
blcnnorrhcea in the lying-in hospitals. No doubt the healthy 
mothers leave the hospital, as a rule, on the Sth to 10th day ; 
if the child's eyes are affected, they arc recommended to bring 
it daily to the hospital for treatment. But it is only very few 
able to do this, most of them must return to their homes 
acconnt of thejr want of funds. The question then arises 
rhether, under such circumstances, assistance should not be given 
by keeping the mother in the institution until the child's eyes 
are cured. 

In the foundling hospitals, as in the lying-in hospitals, the 
'jdiildren are under medical supervision and treatment. Un- 
fortunately in many large foundling institutions the medical 
staff is so overwhelmed with work that it is not able always to 
give the requisite attention to the eyes. 

It is much more difficult to bring under treatment blen- 
irrhceas occurring outside these institutions. These cases 
often turn out badly. When they are not treated at all they 
do better than when mistreated by domestic remedies; the 
instillation of urine, the application of raw flesh and similar 
procedures are apt only to increase the inflammation. 
Hai.teniioff says that midwivcs, in place of insisting that the 
child should be taken to a doctor, often on the contrary dis- 
suade the parents from doing so. 



138 PENALTIES FOR NEGLECT OF 

What should be done in order that the blennorrhoic children 
may be brought under treatment in good time ? It should be one 
of the duties of mid wives to insist upon parents calling in a doctor. 
Par. 7 of the Austrian regulations for midwives imposes a 
penalty on midwives for neglecting to do this. This is also the 
case in Switzerland. This regulation has been of great service 
in the latter country. According to HORNER, since 1865, not a 
single case of blindness from blennorrhoea occurred in the 
Zurich Blind Asylum. 

Midwives should be compelled under penalty to desire the 
parents to call in a doctor in every case of blennorrhoea. If the 
parents neglect to do so, it should be the duty of the midwife 
to give notice of this neglect to the proper authorities, and so 
acquit herself of responsibility. 

I will not here enter into details respecting the mode of 
treatment of blennorrhoea. I may only say this much. If 
only one eye of a child is diseased, the question is how to 
prevent the infection of the other eye. The occlusive bandage 
which protects the sound eye in adults is not applicable to 
infants. Great cleanliness, constant removal of the secretion 
that flows out, making the child lie on the affected side so that 
none of the discharge can flow over the nose into the other 
eye— will in many cases, but not in all, prevent the infection of 
the sound eye. It has also been proposed to subject the sound 
eye to a regular prophylactic disinfection. Iodoform, solutions of 
nitrate of silver and corrosive sublimate have all been proposed 
as disinfectants. Sufficient experience of these methods has not 
yet been obtained to enable us to pronounce positively on their 
value. 



PROrHYLACTIC MEASURES. 1 39 



§ 47. Relying upon what has already been ascertained, 
I may be allowed to make some suggestions relative to the mode 
in which governments may concern themselves about the prophy- 
laxis of blennorrhoea neonatorum. Government regulations can 
naturally only deal with the prophylaxis of blennorrhoea among 
the people which can be entrusted to midwives. Prophylaxis 
in lying-in hospitals and foundling asylums must be left to the 
judgment of their medical staff. Government can no more 
prescribe a fixed method of prophylaxis to their officials, than it 
can confine the chief surgeon of a hospital to a fixed method of 
bandaging. These institutions arc the places where new me- 
thods are tried and put to the test, whereby a constant pro- 
gress in this field is rendered possible. In my opinion it is the 
duty of governments : 

1. To frame suitable regulations for the midwives. 

2. To take care that these regulations are carried out. 

3. To adopt means for teaching the public. 

As regards the regulations to be made for midwives, the 
following points should be attended to : 

1. The midwife who sees a woman some time before her 
lying-in should ascertain if she has a discharge from the vagina. 
If this is the case she should warn the woman of its danger, and 
advise her to see a doctor. 

2. The midmfe after making an internal examination of 
the pregnant woman, should every time carefully disinfect her 
hands. Immediately before delivery the vagina should be 
cleansed by a disinfecting injection. 

3. As soon as the child*s head is born, the midwife should. 



140 REGULATIONS FOR MIDWIVES 

cleanse the still closed lids with a disinfecting fluid. Should the 
course of the birth not allow this, the cleansing of the lids 
should take place before tying and cutting the navel string, or 
at all events before bathing the infant. 

4. In the first, as also in the following baths, the midwife 
should use for cleansing the eyes separate water, sponge and 
towel or linen rag. 

5. After the first bath, a drop of a two per cent, solution of 
lunar caustic is to be inserted into each eye. 

6. After delivery, the midwife should warn the mother that 
the infant may yet get bad eyes by the introduction into them 
of vaginal secretion, and she should inform the mother how in- 
fection may be avoided. 

7. As soon as ophthalmia (even of a slight character) shows 
itself in the infant, the midwife should warn the parents that it i«? 
a dangerous and infectious disease; she should tell them by 
what means the conveyance of the disease to others may be 
avoided, and she should direct them to seek the advice of a 
doctor without delay. If the parents neglect to do so, the 
midwife should report their conduct to the proper authorities, 
in order to get rid of responsibility. A penalty should attach to 
neglect on the part of parents. 

To these points the following remarks may be appended : 
They should only give a general outline of the course to bepursued. 
On this account I have not named any particular disinfecting 
fluid to be used for cleansing the eyes. Where midwives are 
required to have with them a carbolic solution, this would 
naturally be the one employed for the eyelids. 



ABOUT DISINFECTION OF THE EYES. I4I 



For the disinfection of the conjunctival sack, I would advise 
Crede's method, because wherever it has been employed it has 
proved itself the surest I differ from Credit in this, that I 
should require the midwife to cleanse the lids immediately with 
a disinfectant lotion. As we can never place implicit reliance 
on the carrying out of a method by midwives, this gives us an 
additional guarantee that infection will be prevented. 

Some states {e.g,^ Saxony) strictly forbid midwives to treat 
blennorrhoea themselves ; this rule should be maintained, but 
they must in addition be required to give notice in case the 
parents will not call in any doctor. 

The government must provide for the strict carrying out of 
these regulations by a supervision of the midwives, imposing 
penalties for neglect of the directions, &c. When a neglected 
case of blennorrhoea is brought to the doctor and he finds that 
the midwife has not done her duty, the doctor should not only 
be allowed but he should be required to complain of the mid- 
wife. 

The chief objection to the disinfection of infants by midwives, 

is that they do it badly and may thus do more harm than good. 

It is evident that we can only expect a proper execution of this 

method from such midwives as have seen it practised and have 

p>ractised it themselves. Hence : 

I. In future all women educated as midwives, should receive 
F> roper instruction relative to the blennorrhoea of new-born 
i Infants, and learn the prophylactic treatment practically in the 
t^cDspital. For midwives so instructed the carrying out of the 
grcDvernment regulations regarding prophylaxis would then be 
^t^ligatoty. 



142 INSTRUCTION OF MIDWIVES. 



2. What is to be done with midwives already engaged in 
practice ? Some of these reside in large towns where there arc 
schools for midwives. Some plan could be adopted in order to 
attract these midwives for a short time to the institution where 
the requisite instruction may be imparted to them. 

For the majority of midwives who live at a distance from such 
a school,this plan cannot be carried out. Under such circumstances 
the government might act in the following way. It might provide 
them with a plainly written pamphlet, which besides giving full 
instruction about blennorrhoea, should contain a detailed descrip- 
tion of the prophylactic treatment. The midwives should not be 
obliged to carry out this treatment, but they should be at liberty 
to do so. I believe that those midwives who from their own 
inclination, or from desire ' to do their duty should wish to 
carry out the new method, would read the pamphlet with due 
attention and follow its directions. 

I have already indicated how the government may provide 
for the instruction of the public. The introduction of instruc- 
tion for parents in the marriage-book, in popular almanacks, &c., 
will serve to spread a knowledge of this malady. 



Chapter III. BlennorrhcBa acuta adultorum. 

§ 48. Like the blennorrhoea of new-born infants, that of 
adults comes also by infection, the origin of which is to be 
sought either in the genital organs or in another blennorrhoic 
eye. In the former case it is the gonorrhoeal inflammation of 
the male urethra or of the female vagina which furnishes the 



CAUSES OF ACUTE BLENNORRHCEA. I43 

infectious secretion. This is usually introduced into the eye by 
a dirty finger. Cases are recorded (I myself have seen two such) 
where the infection was communicated by a man labouring under 
^onnorrhoea washing his eyes with his own urine (a favourite 
domestic remedy for inflammation of the eye among the 
common people). It seems that even a non-virulent catarrh of 
the vagina may under certain conditions cause acute blennorrhoea, 
which may be as dangerous as that produced by a gonnorrhoea. 
This is shown by the fact that little girls affected with vaginal 
catarrh sometimes get acute blennorrhoea if they bring the 
vaginal secretion into the eyes (v. Arlt* HAUSSMANN,t 
HirschbergJ). — Acute blennorrhoea is also caused by infection 
from another eye suffering from blennorrhoea, whether the latter 
is affected with blennorrhoea neonatorun^ or with the acute 
blennorrhoea of adults. 

Infection by the secretion of diseased genitals or of diseased 
•eyes is apt to attack doctors and nurses especially, because 
when treating such patients some of the secretion gets into the 
•eyes. This is also the case with mothers and wet-nurses who 
suckle children with diseased eyes, and to a still greater degree, 
for such persons are often not sufficiently careful and cleanly. 
Hence in many foundling hospitals a considerable number of 
infected nurses are found. Haussmann gives the following 
figures relating to these foundling hospitals. 



* Krankhdten des Auges, 1881, p. 38. 

t L.C., p. 35. 

X Centralblatt f, Augenhdlkunde^ 1884, p. 311, 



OPHTHALMO-BLENNORKHCEA IN NURSES. 



Kleiin. Cliildrcn. 
2918 



Blenn. Nurses. 
34S (II-S •/.) 



Petersburg 

Vienna 3964 49 (1.23 °/J 

Prague 543 4 (0.73 %) 

PiRiNGER says that nurses in foundling hospitals sometimea 

deliberately infect their own eyes, in order to be dismissed fron; 

the institution on account of their eye disease. 

In spite of the frequent opportunities for infection, acut^ 
blennorrhoea of adults is not very common. According td 
HlESCHBERG it forms r.i8 per mille, according to FlEUZAL," t 
quite 0,5 per mille of all eye diseases. Among i.OOO bliiw 
eyes, COHN found 26 which were lost by gonorrhceal 
junctivitis.- — The acute blennorrhoea of adults is much r 
dangerous than that of new-born infants ; in severe cases t 
best treatment is not always able to ward off an unfortunaH 
result. 

g 49. In the prophylaxis of this disease it suffices to prevei 
the introduction of infectious matter into the eyes. Want ■ 
cleanliness and ignorance are to blame for the neglect of necea 
sary precautions. When patients present themselves for treat! 
ment for gonorrhcea or virulent vagina] catarrh, the physicial 
should obviously call their attention to the danger threatening^ 
their eyes. Unfortunately many persons so affected do nol 
consult a doctor, sometimes from a feeling of shame, sometime^ 
from mere carelessness. — In the army, as a rule, provision 
made for the early treatment of gonorrhcea by the regular 
medical inspections of the men. These are generally made 

" Ccrigrh inlcmal. dHygiine. Geneva, iSS;. Vol, I., p. 225. 



PREVENTION OF INFECTION. 



once a week and are specially directed to the detection of 
venerea! diseases. — When, with the spread of education, atten- 
tion to cleanliness increases among; the poor, the number of 
cases of acute blennorrhcea will be proportionately reduced. 

The communication of blennorrhcea by means of new-born 
l^dren can be prevented in lying-in and foundling hospitals by 
the requisite care and cleanliness. What improved nursing in 
this respect may do, is shown by the Vienna Foundling Hospital. 
In 1812-13, according to the report of JUST, to 100 blcnnorr- 
hoic infants there were 15.7 blennorrhoic nurses ; from 1856 to 
1S63 only 1.23. A still stricter attention to cleanliness would, 
no doubt, diminish still further the number of cases. The most 
effectual means of preventing the communication of blennorrhcea 
from infants to adults would be thestringent adoption of the pro- 
phylaxis of the blennorrhea of the new-born infants themselves 
and that both in and out of lying-in hospitals. The number of 
sucklings with bad eyes would thereby be greatly lessened ; in 
case of the disease appearing the midwife would at once 
acquaint the parents with the risk of infection, and the physician 

Iivho i.s called in would do the same. 
I Physicians and nurses know the danger of infection and 
trotect themselves by proper precautions and cleanliness. 
Host dangerous are the injections made into a blennorrhoic 
l^thra, vagina or conjunctival .sack, whether done for the pur- 
pose of cleansing or introducing medicinal substances. During 
this operation the fluid is apt to spurt out in all directions, 
and may get into the eyes of the operator. Oculists pro- 
Xt themselves by wearing spectacles to protect the eyes; 



146 INFECTION OF DOCTORS AND NURSES. 



as far as I know this is not done by medical practitioners when 
treating gonorrhoea, but they might do it with advantage.* — As 
regards acute blennorrhcea of the conjunctiva, the old method of 
cleansing the eye by syringing is given up in many hospitals, 
and is replaced by other modes of cleansing. Syringing is not 
only dangerous for the nurse but also for the patient's eye, which 
may easily be injured by an unskilful use of the syringe. 

If the disease have already broken out, speedy medical aid 
is urgently needed. If but one eye is affected the other must be 
protected by an occlusive bandage. At the first sign of con- 
junctivitis in the other eye (I do not mean the catarrh which is 
apt to occur in a bound-up eye) I and others besides myself have 
found that the most efficacious treatment is to touch the con- 
junctiva once or twice a day with a two per cent, solution of 
lunar caustic. In some instances I believe I have in this. way 
prevented the occurrence of the disease. This, however, only 
applies to those cases where the disease is seen in its very 
earliest stage. If the disease have become developed cauterisa- 
tion should not be had recourse to until the chemotic infiltra- 
tion of the conjunctiva has receded and copious purulent 
secretion has set in. 

Chapter IV. Trachoma. 

§ 50. Under this name I include, as I have above explained, 
both the papillar and the follicular forms which I regard as 
essentially the same. 



* One of my colleagues, when injecting a gonorrhoeal patient, lost his 
eye by getting it infected in this manner. 



FIRST APPEARANCE OF TRACHOMA. 1 47 



For a long time i was usually believed that trachoma was 
first brought to Europe by the soldiers of Napoleon I. His 
army was attacked by this disease in Egypt, hence the name 
•ophthalmia ^gyptiaca. But the disease has always existed in 
Europe : its occurrence as an epidemic during and after Napo- 
leon's wars only directed general attention to it. Epidemics of 
■ophthalmia were not unknown in former centuries. VoN Arlt 
^ives a long list of them, among these one which raged among 
the soldiers in Westphalia in 176 1. It is not absolutely certain 
but very probable that it was of the nature of trachoma. VoN 
Arlt quotes a passage from Celsus containing an accurate 
-description of trachoma, proving that it was known in Italy in 
the days of the Roman empire. 

The disease is certainly contagious and is propagated by 
infectiojt. It is, however, hard to prove that this is the only way 
in which it arises. In many cases it is impossible ,to prove 
infection. The cause of this is that the disease at first runs 
a completely latent course ; it is only noticed by the patient 
when it has attained to a certain height. On this account other 
causes have been sought for the occurrence of trachoma. VoN 
Arlt who was the first to give a clear description of granular 
trachoma, and to prove it to be a specific form of disease, thought 
that it was dependent on scrofula, and in some instances on 
tuberculosis. HORNER* believes that the granular form is 
caused by miasmatic infection (by foul air), the papillar form 
by contagious infection (by the secretion from a diseased eye). 

* Gerhardfs Handbuch der Kinderheilkuiide^ Bd. V., p. 313. 



148 CAUSES OF TRACHOMA. 

VON Arlt has lately altered his opinion ; he attributes all cases 
of trachomatous conjunctivitis to infection from another eye, 
and in this I agree with him. 

If this view is the correct one and infection is indispensably^ 
requisite for the production of trachoma, there are, however, 
certainly other circumstances which have to do with the produc^ 
tion of the disease, in this way, that they contribute to the 
communication of the disease from one individual to another. 
The differences in the severity and extent in which trachoma occurs- 
depend on the presence or absence of these circumstances. Thus,, 
in former times, as VON Stellwag rightly remarks, there was- 
an absence of the proper foci of trachoma, such as large standing 
armies, numerous educational establishments, orphan houses,. 
&c. The beginning of the present century brought with it a 
considerable increase and extension of this disease, apparently 
by the long wars which brought the armies of all Europe in 
frequent contact with one another and with the civil populations. 
The disease ravaged one country after another in the form of 
widespread epidemics. It was observed with trachoma, as 
with other maladies, when an endemic disease develops into an 
epidemic : it took on a much more acute character. The 
disease was attended with great purulent secretion, whereby 
naturally its rapid spread was still more promoted. 

The spread of trachoma is mainly promoted by the dwel- 
ing together of many persons (in barracks, educational insti- 
tutions, &c.), for thereby the communication of the contagion 
from one person to another is facilitated. The communication is, 
as a rule, effected indirectl}', by the common use of different objects. 



CIRCUMSTANCES FAVOURING INFECTION. 1 49 

such as sponges, towels aiid other washing articles, by washing 
water, &c The necessary antecedent condition is of course the 
presence of a person suffering from the eye affection, from whom 
the infection spreads among his companions. This explains 
why in identical modes of barrack-life, sometimes one particular 
•portion of a body of troops is attacked whilst others remain free, 
if among the latter there was from the beginning no one affected 
with the eye disease. This was the case, for example in Mayence, 
where in 1819 a violent epidemic prevailed among the Prussian 
army of occupation, so that one third (1,146 men) fell ill in a 
few months. The Austrian contingent of the allied army, how- 
•ever, remained quite free from the disease. 

I have already touched on the question, whether infection may 
.also take place through the air, I will not deny the possibility 
of this mode of propagation ; there must, however, be a very 
long sojourn in such vitiated air. MUELLER, who was attached 
to the Mayence garrison during this epidemic, considers that 
.there is no danger in remaining the whole day in a ward filled 
with such patients, but he would on no account pass a night in 
5uch a situation. He believes that the defective ventilation 
^during the night increases the infectious property of the air. 
In schools where there are boarders, those who sleep in the 
establishment are much more liable to infection than the day 
:scholars. .In 1867, COHN examined a deaf-mute institution in 
Breslau ;* of iii children who lived in the institution, 84 had 
trachoma, while not one of the external pupils had the disease, 



* See Hygiene des Auges in den Schulen, p. 170. 



INFECTION THROUGH THE AIR. 



though they spent a gtQ^t part of tlic day with the othi 
But is it really the air that docs harm to those «'ho sleep in sui 
establishments, or not rather the common use of \vashing utensil 
&c. ? The latter appears to mc to be much more probabla 

Though vitiated air may not perhaps be able to eommur 
infection directly, yet it may very likely favour it. A sojoui 
in bad air brings on conjunctival catarrh and particularly 
formation of follicles in the conjunctival sack. Every medii 
man knows the so-called hospital-catarrh, a catarrh of the con- 
junctiva, which attacks many patients who arc long in hospital. 
Among the eyes of school-children, soldiers, &c., we find, besides 
the trachomatous, many suffering from catarrh. In the first 
half of 1870, many schools in Germany ivere medically inspected 
in consequence of a report that an epidemic of Egypti; 
ophthalmia had broken out in the schools, CoHN, Beckei 
Manz, Foerstek, Schkoeder and others on this occasion 
examined a large number of school children.* They found only 
from 0.2°/^ to o.4°/„ of trachomatous children, but on the other 
hand, in from 12 to 18'/, of the children examined, conjunc- 
tival cataiTh and follicles were present, Trachoma is ne\'er 
spontaneously developed from these latter affections, but on 
other hand such eyes are more susceptible of infection when 
secretion of a trachomatous eye gets into them. 

§ 51. As regards the disease among soldifrs, the first' 
accounts we have date from the period of Napoleon's Egyptii 
expedition. At that time almost the whole army (32,000 



tea 



' Revmond made s 



n ihe Turin schools. 



TRACHOMA AMONG SOLDIERS. 15 I 



were affected by it, as also the British troops who were in Egypt. 
During the following twenty years the disease spread through 
almost all European armies. The French army was propor- 
tionately least affected, but on the other hand the disease soon 
became epidemic in all other European armies. From the 
copious literature upon this epidemic I shall extract only a few 
data, in order to give an idea of its prevalence. In the British 
army in 1818, there were more than 5,000 blind invalids as a con- 
sequence of this disease. In the Prussian army from 1813 to 
1 8 17, between 20,000 and 25,000 men were attacked, of whom 
150 lost both, 250 only one eye. In the Russian army between 
1816 and 1839, 76,000 men were affected, of these 876 lost one 
eye, 654 both. In Italy, of 1,500 soldiers attacked with the 
disease, 97 lost one eye, 49 both. In the Belgian army in 1840, 
there was one trachomatous soldier out of every 5 ; up to the 
year 1834, 4,000 soldiers had lost both eyes, 10,000 one eye. In 
Portugal, the disease first appeared in 1849, and then in rather a 
mild form. In 8 years 10,000 soldiers were affected, of whom 
only 55 were rendered quite blind. In 1848 the disease invaded 
Denmark, and in Copenhagen alone out of 6,171 men, 1,156 
were affected. 

At present trachoma no longer occurs in armies with such 
epidemical severity, but it still exists in them. Every year a 
number of new recruits are attacked by it ; many of these return 
home uncured and spread the disease around them. Thus the 
standing armies constitute a permanent focus for the spread of 
trachoma, which is a real scourge in many countries. 

Unfortunately we have no accurate data respecting those who 



TRACHOMA AMONG CIVILIANS. 



get trachoma in the military service and return to civil life wifl 
the disease. We only know how many soldiers are invalidet 
from this cause, but that is only a small portion of all those wlu 
are affected by it. Reich" gives the following data relative % 
the army of the Caucasus in which a periodical inspection of tl 
soldiers is made. Among nearly 40,000 soldiers 2909 sufferer 
from granular ophthalmia = 7.2°/o, but among 3,401 recruits 
there were only 3°/^ of cases, hence we infer that the remainingl 
4.2°/^ first got the disease in the army. 

As in the land army, so also in the navy granular 
junctivitis occurs : it has raged with much greater severity ii 
navy than in the army. According to UHLlKf in 1875 in the 
Austrian navy about every sixth man was affected with trachoma. 
The disease is also endemic in the invalid hospitals and in the 
military training establishments, 

§ 52. From the army the disease spreads among civilians, by 
the dismissal of soldiers affected with it, by billeting, by war. In 
St Hubert in Belgium, for instance, where trachoma was hitherto 
unknown, a severe epidemic broke out in 1S74 after the billeting 
of affected soldiers; the following year the disease had spread 
to such an extent, that hardly any normal eyelids were to be seen 
among the population except among children and old people. J 

Among the civil population, those establishments where a 
considerable number of persons live together, are especially 
favourable to the spread of trachoma. Among these may be 

• Kaukasische medidmschc Gcselhchajt, 1878, No. 36 (cited in Nagel'K 
Jahresberich l). 

t Statisticker Satdtlitsbericht der k.k. Kriegsmarine. Vienna, 1877. 
X Vihsixy^fde rophthaiime graHulsuse dam Im ScoUs. Mons, 1878. 



TRACHOMA IN CIVIL INSTITUTIONS. I S3 



mentioned the orphan houses, foundling hospitals, infant asylums, 
schools, educational establishments, blind asylums, alms houses, 

r 

. work houses, prisons, refuges and asylums of various kinds, &c. 
Among the schools it is especially those where there are boarders 
which are subject to trachoma. In the following list I shall only 
adduce a few instances from the copious literature on the sub- 
ject. In the English educational establishments BowMAN 
found S97c> Nettleship between 50 and 60° j^ of the children 
affected. In the poor schools of Holborn, according to Bader,* 
all the 500 children had trachoma. The same was observed by 
Agnew in the New York Asylum for Children.! Hairion 
found in 1840 in the Orphan Asylum of Mechlin among 66 
orphan girls, 64 trachomatous ; in Mons, among 74 orphan girls 
71 were affected. J In the Dublin workhouse, according to KlRK- 
PATRICK, from 1849 to 1854, no fewer than 134,838 individuals 
were affected. In former times, when the disease broke out on 
"board ship, as the proper treatment was not then so well under- 
stood, almost the whole crew were attacked. A slave ship, 
the Rodeur^ had 22 sailors and 160 slaves on board. During the 
^voyage the disease broke out ; one sailor only escaped. When 
"tie ship reached its destination, 39 negroes and 12 sailors were 
quite blind, many others lost one eye or were seriously in- 
Jured.§ 

Age is not without its influence on trachoma. Children and 



* Lancet^ 1877, p. 235. 

+ The Med. Record. New York, 4th July, 1882. 

t Dastot, 1. c. 

§ Mackenzie, translated by Longier and Richelot. Paris, 1844, p. 309. 



» 



>J 



1 54 INFLUENCE OF AGE, HABITS OF LIFE. jl 

old persons are less subject to it than the intermediate ages. 
According to Saemisch,* 1151 cases of trachoma treated by him 
were distributed according to age thus : — 

From I to 10 years 6.9°/^ 

10 to 20 „ 39.57o 

20 to 35 „ 44-47o 

35 years and upwards 9.i°/o 

I have already mentioned that where many persons live toge- 
ther, it is their common use of various utensils that is chiefly 
responsible for the communication of the disease. The same is- 
the case also outside such establishments. Want of cleanliness is 
one of the most important factors in the propagation oi: 
trachoma. This is much more frequently found among thc2 
poorer than among the well-to-do classes. Its great prevaleno 
in certain countries, e,g,y in Oriental countries and in Irelancl. > 
may to a great degree be referred to uncleanliness and poverty "•^• 
For the same reason certain races seem to be particularly subjec^^ ^ 
to trachoma. In Constantinople, according to MANNHARDT,th '^ 
Armenian porters, who are distinguished for their very dirt 
habits, are extremely liable to trachoma. In Finland, the Fin 
suffer much more from it than the Swedes, who are much bett^^^^ 
off in social respects. The great prevalence of trachom-^c""^^ 
among the Jews is well-known in Holland, as also in th^^-*^^ 
Eastern parts of Europe. 

§ 53. Geographical extent. Certain climatic influences ar"^^ -^^^ 
among the factors which favour the spread of trachoma. Othei^ — ^ 



Handbuch der Augenlicilkunde von Graefe-Saf:misch Bd. IV., p. 63— 



FREQUENCY OF TRACHOMA IN EUROPE. 1 5 J. 

wise it would be difficult to understand why some countries arc 
so much more subject to the disease than others. This is so in 
countries in which the habits of life, cleanliness, &c., are very 
much the same, as for example in different parts of Germany. 

As regards Europe, at the present time, trachoma is most 
prevalent in the Eastern parts of the continent. European 
Turkey, with the adjoining Danubian states, Greece and 
Russia are very subject to it. Thence it spreads to the 
Black Sea provinces of Russia, as also to the Eastern provinces 
of Austria and Prussia. In the Austrian dominions, Galicia, 
Hungary, Croatia and Dalmatia have the largest number 
of cases of trachoma ; it is rarer in Bohemia and Moravia ;. 
in the German provinces of Austria, and particularly in the 
mountainous districts (Tyrol), it is almost unknown. In 
Prussia it is also the Eastern provinces, namely, Prussia, Posen 
and Silesia which suffer most from trachoma. In Middle and 
South Germany the disease is rare. We find it again in the 
Rhine valley, and in increasing intensity as we descend the 
Rhine. In the upper course of the Rhine, in Switzerland and 
Baden, trachoma is seldom seen ; from the junction with the 
Main it begins to be more common, and attains an increased 
extension in Holland and the neighbouring Belgium. 

Trachoma is not generally prevalent in France ; more so in 
Spain ; still more so in Italy, where it is very prevalent. Of 
northern countries Finland has a great deal of it, Norway and 
Denmark less, Sweden hardly any. In Great Britain it is uni- 
\rersally prevalent, but much more so in Ireland (in America 
^Iso the Irish emigrants are the chief sufferers from this 
ciisease). 



IS6 



INFLUENCE OF CLIMATE 



Of non-European countries Egypt is the chief seat of tl 
disease. It is found in like manner in all Northern Africa 
some parts of Algeria almost everyone has it It diminishes ii 
Egj.-pt towards the south, and is rarely met with in Nubia. Tl 
negroes of Central Africa are pretty nearly exempt from it 
on the West Coast of Africa it is again common. There is 
little trachoma in the Cape. 

Asia is pervaded by trachoma throughout its whole extenl 
it is extremely frequent in Arabia, one-fifth part of the populi 
tion is said to be affected by it. Both Indies, China, Jap; 
and Siberia suffer very much from trachoma. The same mi 
be said of the Polynesian Islands, whereas the Anglicised 
of Australia have very little trachoma. In North America, 
Western States are more affected by it than the Eastern. It 
immensely extended in Mexico and South America, except 
the dominions of the Argentine Republic 

In what way climate influences the spread of the disease 
not certainly known. Usually glaring sunlight, heat, dust am 
-dry air are alleged to be the chief noxious agents (i 
Egypt, &c,). But, on the other hand, we find it prevaUii 
-enormously in moist and foggy Ireland. Probably the hei| 
above the sea level has more to do with it ; in Europe the moi 
tainous countries (Switzerland) are free from it; in the Ni 
valley it becomes rarer the nearer wc approach the sources of 1 
river. On the other hand, there are mountainous countries, 
for instance the Caucasus, where trachoma is very rife." 

• Falk gives a detailed account of the geographical distribution q 
irachoma in Schmidt's Jahrbilcher tier gesammten Meiiiciii, VoL CLIX., A 
^09, 1873- 




AND OF RACE. — DANGERS OF TRACHOxMA. 157- 



All races are not equally liable to trachoma. No doubt, as I 
before observed, in judging of races we must bear in mind their 
degree of culture, and not put down as peculiar to race what 
depends only on want of cleanliness, crowded population, &c. 
Burnett and Knapp* allege that the negroes in North America 
enjoy almost complete immunity from trachoma ; and the like 
is reported by travellers in Central Africa. As it cannot be 
asserted that the negroes are superior in cleanliness to the whites 
we must attribute this to a racial peculiarity. 

§ 54. Dangers of Trachoma, — The epidemic of trachoma, 
which prevailed almost all over Europe in the four first decades 
of this century v/as distinguished by its malignant character. 
The acute forms were by far the most frequent. The disease 
began with swelling of the eyelids, copious purulent secretion, 
and the cornea was soon involved. Hence the number of cases 
of blindness was disproportionately large. In the European 
armies on an average O'S to 0'8 per cent, of the soldiers at- 
tacked lost both eyes, a much larger proportion one eye only. 
Uow-a-days the number of those who are rendered totally 
blind is much smaller. The disease assumes a more chronic 
form, giving the patient time to resort to medical aid. The 
knowledge of the disease and of its treatment is more generally 
distributed among medical men than was the case at the time of 
tlie invasion of the epidemic. COHN had among 1000 blind 
^3^es 17 which had been destroyed by trachoma. MAGNUS found 
^tnong 707 cases of total blindness examined by him, 2*2 per 

* Bericht ilber die Heidelbergcr ophthalmologische Versaitimhmg^ 1881 
p. 38. 



158 BLINDNESS FROM TRACHOMA. 



cent, caused by trachoma. Daumas had among 1178 cases of 
bh'ndness of both eyes 5*4 per cent, caused by trachoma, Car- 
RERAS-Arago among 395 blind, 9*1 per cent, from this cause. 

If we look only at the number of cases of blindness, we shall 
not obtain a right conception of the extent to which trachoma 
proves a scourge in many countries. In the chronic form of 
this disease, those affected by it are often for years incapacitated 
for work before turning blind, and no statistician takes account 
of those who after years of suffering do not become totally 
blind, but retain only very imperfect sight What a great loss 
of working power does not that imply for a busy industrial 
country like Belgium, where, in 1830, one sixth part of the 
population were suffering from this disease QUENGKEN). 

§ 55. Prophylaxis, — The same may be said of trachoma as of 
the blennorrhoea of new-born infants : if sufficient care be exer- 
cised no one ought to lose his sight by it. The object of pro- 
phylaxis here also consists of two points : Avoiding communi- 
cation and treatment of the affected persons. 

The communication of the disease will be best prevented by 
stringent separation of the healthy from the diseased. Where 
this cannot be done, everything must be avoided that can effeo\. 
the communication of the infectious matter from one person 
another : living too close together, a common use of washi 
utensils, towels, &c. Good ventilation of localities occupied 
many persons is imperative for other reasons, though we may 
believe in the miasmatic origin of trachoma. In addition 
this, those affected with the malady, and those who come in ccf 
tact with them, should be enlightened as to the infectious cl^ 
racter of the disease. 



It is of great importance to continue the treatment of the 
diseased until they are completely qurcd. In consequence of the 
uxtremely chronic character of the disease, this is very rarely 
attended to, 

I will now proceed to show in detail how these requisites of 
hygiene arc to be carried out in the army, in civil establishments, 
and among the people. 



*l. THE ARMY. 
In almost all countries where trachoma is rife, there c.\ist 
special regulations relating to trachoma among the military class. 
The most thorough and the best of these are to be found in 
Belgium, in whose army trachoma is most prevalent. Many of 
the points I am about to propose agree with the existing regu- 
lations, therefore I will not repeat them in this place. The par- 
ticular points to be attended to in the promulgation of such 
regulations are the following ; — 

I. Before all things it is necessary that military surgeons 
should have a thorough knowledge of this disease. The duty 
of the military surgeon is not only to treat the trachomatous, 
but also to determine what trachoma is and what it is not. In 
order to be able to do this, he needs not only theoretical know- 
ledge but also considerable practical experience. 

.. ^t:c«(i/(K^.— Should trachomatous recruits be received or 

jected? In the German army tlieyare rejected, in the Belgian 

repted, provided they are not too severely affected. I think 

lie latitude should be allowed in this matter. In countries 



l6o RECRUITING.-BARRACKS. 



where trachoma is extremely prevalent, as, for example, in 
Belgium, we should be unable to raise the required number of 
men in certain provinces at least, if we were to reject all the 
trachomatous. Moreover it is to be feared that many conscripts 
would purposely inoculate themselves with trachoma in order to 
escape military service. In such countries the severe forms of 
trachoma (with pannus, &c.) should be rejected, but the slighter 
cases should be accepted. Trachomatous recruits ought not to 
be brought among the healthy soldiers, but should be put where 
trachomatous soldiers are kept. — In countries where little tra- 
choma exists, it seems to me to be better to prevent the infec- 
tion spreading in the army by rejecting all those affected with 
trachoma. 

3. It is essential to avoid overcrowding in barracks, Twent}'- 
five cubic metres of air-space per man should be regarded as the 
minimum. Provision should be made for good ventilation. In- 
former times greater importance was attached to the disinfectior^ 
of the wards, as trachoma was held to be mainly due to miasmatic 
influences. This is no longer the case, and a special disinfection 
does not appear to me to be necessary. But, for other hygienic 
reasons, it is advisable to clear out every barrack ward once or 
twice a year, for a week or two, in order that it may be 
thoroughly ventilated and whitewashed. 

For washing purposes the soldiers should, if possible, have at 
their command a sufficient supply of cocks with fresh flowing 
water. When this is not practicable, each soldier should have 
his own basin and by all means his own towel. In the Belgian 
army every soldier carries his own basin in his knapsack. 



TREATMENT OF TRACHOMATOUS SOLDIERS. l6l 

4. A regular medical inspection of the soldiers' eyes is of great 
importance. This must be done thoroughly, that is, the lids 
must be everted. This is all the easier to do as in most armies 
the soldiers are at any rate examined once a week for venereal 
diseases. In countries where trachoma is endemic a weekly 
inspection of the eyes is obligatory (first introduced in the 
Belgian army) ; where trachoma is rare an inspection once a 
fortnight or once a month will suffice. 

In Belgium there is besides this excellent arrangement, that 
every soldier on applying for furlough is examined, and it is 
only granted to him if he is free from trachoma. In like manner 
he must at once be examined on returning from furlough. 

5. Treatment of the trachomatotis, — A separation as complete 
as possible of the trachomatous from the healthy is the first 
requirement of hygiene. 

How can this be effected ? The severe cases, that is to say all 
those whose cornea is affected or who have a profuse discharge, 
must be sent to hospital. In this there ought to be special wards 
for the trachomatous, and the intercourse between trachomatous 
and other patients must be carefully supervised. For a long time 
there was a central hospital in Louvain in Belgium under 
Hairion for the severe cases which seemed to require a length- 
ened treatment. The trachomatous patients were either kept in 
the hospital until completely cured or until so far advanced in 
recovery that they might be allowed to mingle with the slighter 
cases. 

The slighter cases constitute the great majority, and their 
treatment offers greater difficulties. To these belong the recruits 
II 



1 62 DISMISSAL OF TRACHOMATOUS SOLDIERS. 

slightly affected with trachoma, as also those soldiers whom the 
weekly inspection, shows to be trachomatous. In the Belgian 
barracks there are special wards for trachoma to which these 
soldiers are relegated. The occupants of these wards are placed 
under medical treatment, do not attend drills, and are not allowed 
to go out. This system has some disadvantages. The contact 
of healthy and diseased soldiers is not completely avoided ; the 
diseased soldiers are deprived of fresh air and exercise which are 
very necessary for the trachomatous. For those armies which 
have many trachomatous soldiers it would be much better to 
bring them all together (except the severe cases) in one barrack. 
This ought to be situated in a healthy locality, free from dust, 
and where possible in a hilly situation ; the soldiers should be 
under medical treatment and in addition they should go through 
the military exercises, but not to a very fatiguing degree. The 
-establishment of such barracks has been recommended by others 
(Peltzer, Fialkowski). With suitable arrangements such 
barracks may also be used in winter. 

6. Dismissal from Sefvice, — No trachomatous soldier should 
be allowed to quit the service, in order that he may not spread 
the disease in his home. In consequence of the long duration 
of the treatment of the disease it may be feared that thereby a 
great burden would be imposed on the State. But if the regu- 
lations concerning trachoma are strictly carried out, this would 
not be the case. In recruiting only the slight cases would be 
accepted and at once put under treatment ; in the weekly inspec- 
tion every fresh case of infection would be immediately detected 
and subjected to treatment ; thus severe and long lasting cases 



REGULATIONS FOR SOLDIERS. 1 63 



would be only exceptionally encountered. Only those cases in 
which there is a considerable discharge should be kept back, the 
others might be sent home. But it often happens that a tracho- 
matous subject does not put himself under treatment because he 
has no discharge and . suffers no inconvenience, and a few weeks 
later he gets a fresh relapse with copious discharge. No tracho- 
matous person is safe until he has been thoroughly cured. The 
following precautions seem to me to be needful : — 

(a) For Countries with much Trachoma. 

1. In recruiting only the slight cases should be accepted and 
immediately put under treatment. 

2. In the barracks there should be at least 25 cubic metres 
of air space per man. The wards must be well ventilated and 
stand empty and be whitewashed for a fortnight per annum. 

3. Every soldier should have his own washing basin and 
his own towel ; where practicable running water should be used 
for washing. 

4. A medical inspection of all soldiers should be made once a 
week. Further, every soldier going on furlough and returning 
from furlough should be inspected. No furlough should be 
granted to a trachomatous soldier. 

5. Severe cases of trachoma should be sent to the military 
Tiospital, and treated there in special wards. The slighter cases 

should be put all together in a barrack, and there treated. Where 
this is not possible, there must be special wards for the tracho- 
matous ; intercourse of these soldiers with healthy ones should 
as far as possible be prevented. 



164 TRACHOMA IN CIVIL INSTITUTIONS. 



6. No trachomatous should be allowed to quit the military 
service until quite cured. 

(b) For Countries with little Trachoma. 

1. In recruiting all trachomatous subjects should be rejected. 

2. Medical inspection of all soldiers should be made every 
four weeks ; all soldiers returning from furlough should also be 
'nspected. 

3. Everyone suffering from trachoma should be sent into hos- 
pital and treated there until thoroughly cured. 

4. No trachomatous soldier should be dismissed from military 
service until he is thoroughly cured. 



If. CIVIL ESTABLISHMENTS. 
§ 56. As regards civil establishments, there is a difference 
between such as have boarders and those that have none. It is 
in the former especially, where trachoma occurs endemically, 
that its spread is promoted by sleeping and washing in com- 
mon. Establishments with boarders are foundling hospitals, 
infant asylums, educational and orphan homes, many schools, 
blind institutions ; then, again, workhouses, prisons, almshouses 
(to these belong the military invalid establishments), hospitals, &c. 
For these establishments the same principles are applicable as 
for barracks. Modifications are of course required according to 
the arrangement and object of the establishment and the charac- 
ter of their occupants. It makes a difference whether trachoma 
h or is not prevalent in the neighbourhood. 



REGULATIONS FOR CIVIL INSTITUTIONS. 1 65 

I subjoin a brief statement of the prophylatic measures that 
are applicable to establishments with boarders. 

1. The establishment must fulfil the general requirements of 
hygiene ; sufficient air space in the wards, a good ventilation, &c. 
It is very important that the ablutions of the residents should 
be performed either with running water or that each should have 
his own basin, and, of course, each should have his own towel. 
It has been positively ascertained that many epidemics occurring 
in such establishments have been caused by infection by means 
of washing water and towels. 

2. Every candidate for admission into the establishment should 
be subjected to medical inspection in regard to the state of his 

, eyes. If the purpose for which the establishment exists allows 
of it, the trachomatous should be rejected ; if they are received, 
they must be treated in the manner I am about to relate. 

3. In places where trachoma is endemic, frequent medical 
inspection should be instituted ; if necessary, once a week. 

The inspection should be made of all the residents in the 
establishment except the officials ; but the inferior class of these 
(servants, nurses, &c.) should be inspected. In places where tra- 
choma is rare, these inspections should be made at longer inter- 
vals. As most establishments have their own medical officers, 
such inspections may be easily arranged. When this is not the 
case, it should be obligatory on the authorities of the establish- 
ments to have every resident suspected of an eye disease medi- 
cally examined. 

4. The separation of the trachomatous from the healthy is a 
matter of the greatest difficulty. In establishments where there 



1 66 SEPARATION OF THE TRACHOMATOUS. 

arc very many trachomatous there ought to be a separate 
department for them, so that they should not come in contact 
with the healthy. At Mons, in Belgium, when trachoma was 
very prevalent there, a special dcole infirmerie was arranged for 
the trachomatous children. In this school these children were 
educated, and at the same time subjected to medical treatment* 

The following arrangement might be made : in each category^ 
of establishments a department might be devoted to the recep- 
tion of the trachomatous residents. Thus, for instance, one of 
the orphan houses of the country might be arranged for tracho- 
matous orphans, who should be transferred hither from all the 
other orphan houses. The same might be done for all the other 
establishments, such as prisons, almshouses, &c. 

In many cases a complete separation of the trachomatous fronb 
the healthy is not possible ; either from external causes, or in con- 
sequence of the small number of the trachomatous such a stringent 
rule may not seem to be absolutely necessary. What is to be 
done under such circumstances? Those cases where there is a great 
discharge must not be allowed to mingle with the healthy ; they 
should go to the hospital. Those cases where there is little or no 
discharge might in my opinion be allowed to associate with the 
healthy during the day, in the same school-rooms, working rooms, 
&c. In the examinations of the German schools by COHN,. 
Manz, &c., which I have mentioned above, it was shown that la 
all the schools there was a small number of trachomatous children 
(2 to 4 per mille), from whom however the disease was not com- 



Dastot, dc V Ophthalmic gramileuse dans les dcoles, Mons, 1878. 



DISMISSAL OF TRACHOMATOUS PATIENTS. 167 



municated to the other children. The greatest danger, as I 
believe, is incurred by sleeping together. Therefore the tracho- 
matous should have separate sleeping apartments, and the greatest 
care should be taken not to allow trachomatous subjects to be 
iutroduced into the sleeping apartments of the healthy; but 
healthy and diseased might perform their day work together. 

6. Under no circumstances should uncured trachomatous 
cases be sent home, where not only would their eye disease be 
neglected, but they might communicate the disease to their fami- 
lies. For this reason the breaking up of an establishment, which 
used formerly to be adopted, is objectionable. Instead, however, 
of keeping the trachomatous in the establishment until they arc 
cured, it would be better to send them into convalescent in- 
stitutions, where such cases, under the influence of good air and 
moderate exercise, are much more quickly cured. 

As regards day scholars or pupils, they run no risk of infection 
in the school, if the cases with much discharge are excluded. 
The supervision of the eyes of day scholars and boarders is one of 
the most important duties of the school doctor. I have given 
some hints respecting the organization of such institutions when 
treating of school-myopia. As regards trachoma, the duties of 
the school doctor are the following : 

a. Regular inspection of the eyes of the school children, the 
frequency of which should be determined by the prevalence of 
trachoma in the locality ; those suffering from eye affections should 
be pointed out to the doctor by the teacher. 

b. The school doctor decides whether the trachomatous 
scholar should be allowed to pursue his studies or not. The 



i6S 



SUPERVISION OF SCHOOLS. 



former should only be permitted to the slight cases withouj 
discharge. 

c. All diseased scholars should be obliged to submit to mcdici 
treatment. The parents of the scholars should be made respon* 
sible for their regular treatment There should be penalties ft 
the parents' neglect, just as there arc now for non-attendance at 
school in those countries where compulsory education exists. The 
treatment of the affected children may be carried out by the school 
doctor. If the parents prefer to have their children treated by 
another medical man (the family physician or a specialist) they 
should be free to do so. But in that case they should be obliged 
to get a certificate from the physician they emploj', to the effei 
that the child is under his regular medical care, 

d. In all cases the school doctor should alone decide when 
child should again be allowed to receive instruction in comm( 
with the others. 

e. On the breaking out of an epidemic of trachoma it will be 
necessary to shut up the school. In countries where there 
much trachoma parallel schools for the trachomatous may 
established as at Mons. — The school doctor should fumi 
regular reports containing the results of his examinations. 



hey 
gedj 

I 



III. THE GENERAL CIVIL POPULATION. 

§ 57. The treatment of trachoma among the civil populatiol 
is attended with the greatest difficulties. The trachomatous a 
often prevented from obtaining regular treatment by their distance 
from the doctor, by their occupations or by carelessness. Moreover ^■ 
the treatment is such a long affair, that even the most persevering] 



PROPHYLAXIS OF TRACHOMA. 1 69 

sometimes get impatient. Hence many authors have declared 
that all efforts in this direction are in vain. I do not go so far 
as that, on the contrary I think the following rules are calculated 
to effect a diminution of trachoma. 

a. It should be the duty of the physician to report to the 
sanitary authorities either all trachomatous patients or at least 
those who in consequence of great discharge or other circum- 
stances are liable to spread the disease. Medical practitioners 
are obliged to do something similar respecting many infectious 
diseases. I do not doubt that such a regulation is capable of 
being carried out. We could not indeed expect that every tra- 
chomatous patient should be conscientiously reported by his 
medical attendant Thus the wealthier patients of private prac- 
tice would often enough fail to be reported ; but in these cases it 

I 

is less important than in the poorer classes. On the report of 
the attending physician being received the parish doctor should 
visit the patient. If he lives in a family the other members of 
his family should be examined, and if any of them are found to 
be affected they should be warned of the serious character of the 
disease, and the necessity for its treatment. They should be told 
how to avoid communicating the disease. If the patient resides 
in a lodging-house, a crowded locality, or the like, the other 
occupants of the room should be examined and the necessary 
information imparted to them. The landlord of the lodging- 
house should see to it that each of the occupants has his own 
^vashing apparatus. If this precaution is neglected or if the 
locality does not come up to the standard of hygienic require- 
'i^ents, there are laws under which proceedings may be taken 
^g'ainst the landlord. 



170 KINDS OF CONJUNCTIVAL DIPHTHERIA. 

b. The treatment should be facilitated to the patients as much 
as possible, by the establishment of dispensaries, &c., respecting 
which I shall have something to say hereafter. For cases with 
profuse discharge, which are particularly dangerous to their 
neighbours, it might perhaps be advisable to make their medical 
treatment compulsory. 

(b) Diphtheric Conjunctivitis. 

§ 58. Diphtheria of the conjunctiva attacks as a rule chil- 
dren under 10 years of age. The cases are divided into two 
groups according to their origin. The cases of the first group 
are produced by an increase of conjunctivitis. This latter rnay 
be of catarrhal nature ; those catarrhs that accompany measles 
and scarlatina sometimes take on a diphtheric character. But the 
acute blennorrhoea of newborn infants and that of adults may 
also become diphtheric. The form it assumes in such cases 
is the patchy kind. These cases occur sporadically, and are 
usually of the less severe kind. 

The cases of the second group are referable to infection by 
the diphtheric poison, hence they often occur epidemically. 
These are usually the severe cases. There is often simul- 
taneously present diphtheric inflammation of the fauces and 
larynx with severe general illness, so that not only the tyts^ but 
the life of the children are in jeopardy. — The diphtheric contagion 
is allied to the cases of the first group ; so that it is chiefly in 
countries where diphtheria is endemic, and at the time of 
epidemic of diphtheria that other conjunctival inflammation 
show a tendency to become diphtheric. 



SPREAD OF CONJUNCTIVAL DIPHTHERIA. 



I7i 



Epidemics of diphtheria were principally observed in VON 
Graefe'S clinic in spring and autumn.* Emmekt in arranging 
the answers to the enquiries he sent out, found that the 
maximum of cases occurred in January (24 cases), the minimum 
in August (12 cases).t 

Like trachoma, diphtheria prefers certain localities, and" 
spares others. It is met with most frequently in North Ger- 
many, where also diphtheria of the respiratory organs is most rife.. 
In Middle and South Germany it is rare ; the same is the case in 
all other European countries ; Holland alone seems to be an 
exception. In the following I give a short account of its^ 
prevalence in some countries. I have purposely only taken 
statistics where the figures are large, as the disease is rather rare, 
and in a small number of patients accident plays too great a part.. 



Country. 


Town. 

"Konigsberg 


Author. 

... Jacobson 


Total number 
of patients. 

. 10,000 


Cases of diphth 
per mille. 

... 6.2 




Berlin 


... Hirschberg .. 


. 21440 


... 2.0 




Berlin 


... Scholer 


. 10,000 


... 0.6 


Germany-! 


Diisseldorf 


... Mooren 


. IO8416 


... I.I 




Leipzig 


... Coccius 


. 7,898 


... 0.2 


- 


Heidelberg 


... Becker 


. 7,547 


... 1.2 




^Stuttgart 


... Berlin 


. 9,827 


... 1.2 


Holland... Utrecht 


... Bonders J 




... 2.3 



* Saemisch, in the Handbitch der Aiigenheilkundc von Graety. tmd 
^-^liMISCH. Bd. IV., p. 106. 

t International Medical Congress held in London in 1881. 
X Bonders' statistics refer to the years 1870 — 73, and include 3000 
:ients. 



172 BLINDNESS FROM DIPHTHERIA. 

Austria ... Vienna ... Adler ... 12,000 ... 6.2 

France ... Paris ... Fieuzal ... 34,577 ... 04 

England... London ... Moorfields 1 ooT-^r. r^o 

Hospital j ••• -^'^30 ... 0.2 

As regards Austria, which is remarkable for its large propor- 
tion, I should state, that until some twelve years ago, diphtheria, 
whether in the eyes or throat and larynx, was almost unknown. 
In the beginning of 1870 the disease began to spread from 
Germany into Austria and assumed the form of a severe 
epidemic. Adler's report given in the above statistical 
table includes several such epidemic years : 1874 alone furnished 
forty-six cases. 

Diphtheria is a disease that is very dangerous to the eyes, 
quite apart from the fact that many children succumb to the 
general illness accompanying it. 

Horner states that 

Under V. Graefe, out of 46 cases 9 
„ Hirschberg, „ 94 „ 35 
„ Jacobson, „ 22 „ 5 

eyes were totally blinded, whilst many eyes were much injured. 
According to the statistics of blind persons furnished by COHN, 
diphtheria was the cause in 0.3 °/^ of all blind cases, MAGNUS 
gives nearly the same figures (0.356 ""IJ. 

The prophylaxis of diphtheria demands still greater car^^ e 
than that of acute blennorrohcea. The diphtheric infection ma— _y 
be effected without direct communication of the secretion. Wh g==. n 
therefore one child in a family falls ill of diphtheria, the oth — <?r 
children should, if possible, be removed, and only those shou^^ld 



PROPHYLAXIS OF CONJUNCTIVAL DIPHTHERIA. 173. 

remain who are required for attendance on the patient. Hence, 
treatiiient in a hospital is imperatively necessary in the case of 
poor people. As in the case of many infectious diseases, so in 
this disease the transference of the patient to a hospital should be 
compulsory, whenever the necessary nursing cannot be carried out 
at home. There should be separate rooms for diphtheric patients 
in the hospitals, otherwise there will probably happen what 
Adler observed in a children's hospital during an epidemic, 
where diphtheria spread from bed to bed. The greatest pre- 
cautions should be exercised by physicians and nurses to prevent 
the diphtheric secretion getting into the eyes ; especial care is 
required to obtain good ventilation. During the epidemic of 
diphtheria in the Vienna children's hospital just alluded to, all the 
assistant physicians and eleven nurses who had to do with the 
affected wards got inflammation of the conjunctiva, which was 
however of a slight character and passed off in a short time 
without bad effects. 

When one eye is already affected the other eye must be 

« 

protected from infection by a bandage that occludes it com- 
pletely. In one case Alfred Graefe arrested the disease 
when profuse secretion was present, by brushing over the con- 
junctival sack a one per cent, solution of carbolic acid and 
covering the eye with a bandage also soaked in the carbolic 
olution. 



Part VI. 

Influence of the Occupation on Eye- 
diseases. 

§ 59. The affections caused by the occupation are partly 
non-traumatic, partly traumatic. The principal of the former is 
myopia. Myopia is the malady of the learned professions. But 
certain trades also bring the eyes in danger of becoming short- 
sighted. To these belong all trades which require minute and 
long continued looking at objects close to the eyes. COHN 
examined a large number of artisans in Breslau for short sight 
He found among the 

Watch-makers 9.7 7o of myopes 

Gold and silver workers ... ... 12 °/o 

Lithographers 45 °/o 

Compositors ... ... ... ... 51 ^/^ 

Emmert found a larger proportion of myopes among th 
watch-makers ; in four Swiss watch-makers* schools the proper — 
tion of myopes was 14 %•* MOTTAlsf examined 97 com — 
positors, of these 5 1 were short-sighted. With these data the lists 
of trades conducive to myopia is by no means exhausted ; to itS 

♦ 'SAGElJH/a/ircsderu'/i/for 1877, p. 368. 

t Ifygihie dc la viic chcz Ics lypographs. Paris. 1883. 



» 



>» 



»» 



PREVENTION OF MYOPIA IN WORK-PEOPLE. 1 75 

may be added tailors and seamstresses, shoemakers and many 
other artisans. 

TSCHERNING arranged in six classes 7,523 persons examined 
by him, according to the demands made by the occupation of each 
upon the eyes. The number of the short-sighted rises from 2°/^ 
in the lowest class, to 32°/^ in the highest. 

It is remarkable — especially after Cohn's investigations — 
that there are so few short-sighted individuals among the watch- 
makers and workers in gold. COHN says this is mainly owing 
to their employment of a lens which renders both accommoda- 
tion and convergence during work superfluous. This gives a 
hint as to how such artisans may protect themselves from 
short-sightedness, they ought to use the lens diligently. 

Good illumination of the work-shop is of the greatest im- 
portance. The rules laid down for the lighting of schools are 
•generally applicable here. The light should come in sufficient 
quantity and from the proper side. In many large factories 
more care is exercised as regards lighting than in most schools. 
The new factory buildings are mostly provided with numerous 
windows or with roof-light ; the electric light has been very often 
introduced as the artificial illuminant ; the older factories often 
leave much to be desired. Printing establishments in particular 
are often in very dark localities, and this may be the cause of the 
la.rge number of myopes among compositors ; still worse is it, as 
a rule, in the work-rooms of artisans working by themselves. 
Good work-rooms and good methods of illumination are very 
necessary. I shall recur hereafter to this subject. 

Of non-traumatic eye diseases, I may mention here those 



176 ABSCESS OF THE CORNEA. 

caused by lead-poisoning, of which I have already spoken. The 
blepharitis and conjunctival catarrh so often caused by the 
occupation, the nystagmus of miners, &c., do not seriously en- 
danger the sight and so need not be treated of here. 

Abscess of tlie cornea (hypopionkeratitis, ulcus serpens) 
occupies a middle place between spontaneous and traumatic 
eye diseases. In most cases a slight injury gives the impulse 
whence, with the concurrence of other factors, the abscess is 
developed. Of such factors I may mention in especial the pres- 
ence of infectious germs in the conjunctival sack (conjunctivitis, 
dacryocystoblennorrhoea) as also great heat. It is well known 
that abscess of the cornea is particularly prevalent in summer. 
Emmert* has shown that it has its maximum in August 
(411 cases), its minimum in December (191 cases).' Hence it is 
so frequently met with in reapers who work during the hottest 
days of the year, and are subject to frequent small injuries to the 
eyes (by the beard of the com) — (k^ratite des mftissoneurs). 

Abscess of the cornea is by no means a rare disease. Accor- 
ding to HiRSCHBERG^S statistics,f it constitutes 0.5°/^ of all eye 
diseases. It is more frequently encountered among country folk 
than among town folk. MartinJ found that among the former 
6f\^, among the latter only from 8 to io7o of the cases of 
blindness were caused by abscess of the cornea. Many circum- 
stances contribute to this result. This kind of injury (superficial 
scratching of the cornea by ears of corn, branches, &c., seems 



* London International Med. Congress^ 1881. 

t Beitrdge zur praktischeji Atigoiheilkunde^ 1878, p. 102. 

J Association Fran^aise^ &c., Session ^ la Rochelle, 1882. 



INJURIES TO THE EYE. 1 77 

to be particularly dangerous in this respect), the frequency of 
chronic catarrh of the conjunctiva, neglect of the disease in the 
commencement. In abscess of the cornea speedy and energetic 
treatment is attended with a success such as few other diseases 
can show. The number of eyes lost by abscess of the cornea 
would be much diminished if on the one hand the intelligence 
of country people were greater, and on the other if they could 
more easily obtain medical aid. 

There is no actual prophylaxis of abscess of the cornea, 
unless it be the treatment without delay of chronic affections of 
the conjunctiva and lacrimal sack ; accidental injuries that are 
the exciting cause of the abscess cannot as a rule be avoided. 

§ 60. Injuries to the eye in the narrower sense of the term 
are very frequent causes of blindness. FlEUZAL* had among 30a 
blind persons in the Hospice des Quinze-Vingts in Paris, 9.8°/^ 
of blindness from injuries. Other records agree very nearly with 
this. Magnus in his tables, makes the proportion of traumatic 
blindness 8.5°/^. Among the blind persons in Austria, the 
cases due to injuries come to 7.9°/o (about i in 20,000 inhabi- 
tants). Much more numerous are the cases of blindness of one 
eye from injuries ; according to COHN they constitute 24.2"/^ of 
all (one-sided) blindness. Many of these unfortunates live in 
constant danger of losing the other eye by sympathetic inflam- 
mation. 

Blindness occurs either by direct injury to both eyes (simul- 
taneously or successively) or by the injury of one eye causing sym- 



* IV, Congres d* Hygiene, Tome I., p. 218. 
12 



1 78 RELAnVE FREQUENCY OF INJURIES 

pathethic disease of the other. The former category comprises 
47o, the latter 4*57o of all cases of blindness (MAGNUS). The 
injuries are produced either by the occupation, or by accident, or 
by carelessness, or by design on the part of others. Among men, 
the blindnesses caused by the occupation are the most numerous, 
among women and children those owing to accident or care- 
lessness. The injuries which destroy both eyes simultaneously 
occur chiefly whilst engaged in the occupation ; explosions of 
gunpowder, burning with lime, injuries caused by fire-arms, &c. 
According to MAGNUS 4-Sths of all the cases where both eyes 
are simultaneously injured are caused by the occupation. 

The several kinds of occupation vary very much in regard to 
this danger. CocciUS gives the following list of injuries to the 
4^ye observed by him in 1868 and 1869 :* 

Locksmiths... 

Handicraftsmen 

ivxasons ... ... ... ..• 

01111L119 ... •■• ... *•• 

Machine makers 

■L T X X A 1 \^ AO ••• ••• ••• ••• 

Carpenters ... 
Stone-masons 
Metal turners 

.357 
These figures are too small to allow us to form definite con- 
clusions, but they give a good idea of the danger e.g-,, of the lock- 

* Quoted by MAGNUS, p. 197. I have put both years together. 





67 




43 




23 




22 




18 




14 




8 




6 



TO THE EYE m DIFFERENT TRADES. 179 

smith's trade. — Two large categories of injuries are not included 
in this list : injuries received in war, which are injuries incident 
to an occupation, and injuries to miners. The latter are ex- 
tremely common in coal mining districts. 

In the injuries incident to occupation, carelessness and inex- 
perience of individuals have much to do with their production. 
Hence, children employed in factories are very liable to injuries. 
This is evident from the following little table, given by Layet, 
where the frequency of injuries in general are given among 
workpeople of different ages. Of 100 injuries, there were — 

Among children under 15 years old 41 

„ workpeople from 15 to 25 years old ... 36.4 

„ „ „ 25 to 40 „ ... 1 3.1 

„ 40 to 60 „ ... 9.5 



» » 



1 00.0 
It is easy to understand that children will supply a large 
contingent of the injuries caused by accident. Their liability to 
injuries is promoted by the heedlessness of parents, who allow 
them to play with dangerous toys, such as percussion guns and 
such things. Seidelmann* had, among 233 cases of blindness, 

40 caused by injuries incurred by children in their play. 

I shall now proceed to consider the several kinds of injuries. 

a. Injuries to the eyes by burns, — Among these are reckoned 
jiot only the injuries caused by the contact of the eye with 
heated bodies or with flame, but also the injuries caused by 



* Zur Aetiologie und Prophylaxe der Erblindungen. Inaug.-Dissert^ 
Breslau, 1876. 



iSo IN7URIES FROM FOIvEIGN BODIES. 

corrosive substances, such as lime, strong ac:ds. S:c. The most 
frequent of these are the injuries caused by lime or mortar ; in. 
the list given by Cc»CClUS of injuries caused in this way masons 
contribute 12' .. 

t. Injuries hy fcreig?: todUs, — These constitute the majority 
of injuries. The small metallic particles which fly off as sparks 
vrhen iron is hammered, &c., when the\" hit the eve. often remain 
Sticking in the cornea. They are usually removed from the eye 
more or less skilfully by some workman in the factor^-. The 
numerous cases which come to the hospital constitute only a 
small part of those that daily occur. Besides metallic particles, 
fragments of stone are a frequent cause of these superficial in- 
juries among stone-breakers, stone-m*asons, millers, &c- Among 
workpeople who grind metal 'steel on stones, we often find a 
particle cf metal in the cornea in place of the stone particle \kVL 
m:>:ht have exoected. 

WTien the foreign bodies are larger and impinge upon the ej^e 
with greater force, the\- perforate its membranes and penetrate 
into the interior of the eye. Eyes injured in this manner are 
generally lost, and, moreover, they are ver\-apt to occasion sym- 
pathetic ophthalmia. 

Injuries by foreign bodies are much more frequently- met with 
among workers in metals. In the table given above of 357 in- 
juries 'severe and slight together which COCCIUS observed in 
two years, 207 '58' . occurred among workers in metals. Of 
7S3 severe injuries to the eye in the Munich clinic, 183 (33'/ ) 
occurred among workers in iron, 127 ^16' .) among workers in 
^tone. 



INJURIES FROM EXPLOSIVE SUBSTANCES. l8l 

The investigations of COHN are very interesting. He states 

that every single one of the 1,283 workers in metals from six 

factories, examined by him, suffered two or three times a year 

irom injuries to the eye. About one-half of those injured (633) 

were compelled to seek medical aid ; of these, 36 (2.8°/^ of the 

■total number) were partially deprived of sight; 16 (1.2°/^) lost 

the sight of one eye totally. On carefully examining the cornea 

of one of these workmen who come to the hospital on account 

•of a foreign body in the eye, we may often find about a dozen 

small point-like opacities in the cornea, which have all been 

■caused by foreign bodies. Very little is wanting to cause such a 

foreign body to penetrate the cornea or sclera and so bring the 

•eye into great danger. 

c. Injuries from explosive substances. — Most of such injuries 
are caused by the explosion of a powder mine. They are often 
characterised by a combination of burn and injury by a foreign 
body. The foreign bodies found are grains of powder, as also 
particles of the exploded material, stone, sand, coal, &c. 

Injuries by gunpowder are usually much more dangerous 

tiian simple injuries by foreign bodies, not only on account of 

• tiheir greater intensity, but also because they generally involve 

both eyes. As injuries by foreign bodies are frequent in the dis- 

-'tricts where there are iron manufactories, so injuries by gun- 

I>owder are most common in coal mining districts. According to 

irAYET, of 106 persons rendered blind by injury in Liege (1832- 

.38), 60 of them lost their sight by gunpowder explosions in coal 

mines. This we can easily understand, when we are aware of 

the incredible carelessness sometimes displayed by miners. 

Injuries by explosive substances are met with in manufac- 



1 82 INJURIES BY BLOWS, THRUSTS, ETC. 

tories where they are made, among persons who have to do with 
fireworks, among gamekeepers, &c. Children furnish a large 
number of the injuries caused by explosives. Sometimes they 
secretly obtain the explosive substances, like percussion caps, 
&c. ; sometimes they are given to them as toys (percussion-cap 
toy-pistols, fulminating preparations, &c.) BoiSSONEAU, the 
well-known Paris manufacturer of artificial eyes, found that 
among 3,984 persons who applied to him about an artificial eye, 
939 had lost their eye in childhood. Of these, 343 had their 
eye destroyed by letting off percussion caps, or by fire-arms. 
I may mention here that exploding toys are not the only dan- 
gerous ones. Pea-shooters and catapults, the missiles from 
which hit the eyes of the companions of the children who use 
them are frequent causes of loss of sight. 

d. Injuries by blows, thrtists, pricks, &c, — These injuries are 
generally caused by accident, which cannot be foreseen and conse- 
quently cannot be avoided. They are not, therefore, like the 
injuries by foreign bodies in the narrower sense of the term, 
attributable to definite occupations. In the country, cows are 
often the cause of such injuries, by thrusts of their horns or 
blows with their tails when being milked. Such injuries are fre- 
quent among children, who incur them themselves, or cause them 
in others. Finally, most of the injuries purposely inflicted be- - 
long to this category. 

e. Injuries iTicurred during war, — The following table, given 
by Reich,* shows the frequency of injuries of the eye in propor — 
tion to the total of the wounded : — 



* Zehender*S Klzn. Monatsbiatter, 1879, P- 98. I have modified th< 



INJURIES GOT IN WAR. 1 83 



No. of all the Injuries to Per 

Wounded. the Eye. Mille. 

American Civil War ... 408,072 ... 1,190 ... 2.9 
German-French War ... 75,321 ... 464 ... 6.1 
Armenian War ... 13,091 ... 290 ... 22.1 

This table does not show how many eyes were so seriously 
injured that they were destroyed. 

As regards blindness from injuries received in war, COHN* 
gives the following data : — In the Italian-Austrian war (1859) 
there were 55 cases of shot-wounds of the eyes, with 19 cases of 
blindness of both eyes ; in the Crimean war 46 eyes, in the last 
English campaign in India 13 eyes were lost. 

About one-half of those who are blinded by injuries, lose the 
second eye not by the injury itself, but by sympathetic ophthal- 
mia. This occurs, as is well known, almost exclusively after 
injury to one eye. It is a constant source of danger to those 
who continue to retain an eye blinded by injury (especially 
when it is shrivelled up). Though we arc unable to prevent 
most injuries, we can usually ward off the sympathetic ophthal- 
mia. Every case of sympathetic blindness is the fault, some- 
times of the physician, who has not perceived the threatened 
danger in time, but much more frequently of the patient, who 
has sought medical aid too late, or has refused to submit to the 
p>roposed operation. 

Blindness also comes on after injuries which do not affect the 

t^ble so as to give for all the three wars the percentage of eye-injuries to the 
"total number of the wounded. The high percentage in the Armenian war is 
O'ving to this, that it is based on the observations of an oculist (Reich) who 
^oted the most unimportant injuries to the eye. 

* Schussvetletzungen des Attgcs^ Erlangen, 1872. 



1 84 



PROPHYLAXla OF INJURIES. 



eye directly, but the bkull. Such cases, according to MAGNUSj 
constitute 0,27°/^ of all cases of blindness. The mode in whi«^ 
injury to the skui! leads to blindness is very various; in man^ 
cases Berlin" has demonstrated that fractures of the bone, c 
pecially in the optic canal, are present, which cause bruises anw 
lacerations of the optic nerve, 

§ 61. Prophylaxis of injuries. — Those injuries that are caused 
by accidents or by human malice cannot be foreseen and hence 
cannot be provided against. The same may be said of injuries 
incurred in war. Prophylaxis is chiefly possible for those in- 
juries that arc the consequences of certain occupations. This_ 
prophylaxis is made up of the following points : — 

1, In manufactories where explosive matters are made, i 
magazines where such substances are stored and sold, strict rul^ 
should be enforced in order to prevent the danger of exploslo] 
as much as possible (prohibition of smoking, arrangements abi 
lighting, &c.). 

2. The flying off of small particles in the working of nictal 
and stone cannot be altogether avoided. Therefore, the w 
man must protect his eyes by spectacles. These should be ) 
ciently large to protect the eyes not only in front, but at t 
sides. Glass, as being too brittle, may be replaced by fine wir^ 
net or mica (CoHN), All spectacles have this disadvantage — 
that they soon become dirty from dust which is deposited on 
them, from the workman's perspiration, &c. This is espi 
the case with the wire-net, the fine holes of which soon 1 



PROTECTIVE SPECTACLES FOR WORKMEN. 1 85 

stopped up. The workman sees but dimly through the dirty 
spectacles, and leaves off wearing them. This is why, with few 
exceptions (stone-breakers), workmen cannot be persuaded to 
wear spectacles. For some time I presented every workman 
who came to my clinic on account of a foreign body in the eye, 
with a pair of protective spectacles, until I became convinced 
that they were not used by these workmen, not even by those 
who had already lost one eye and should have become wiser by 
experience. 

If workpeople are not prudent enough to protect their eyes 

by spectacles there is nothing to be done but to make the wearing 

of them compulsory. There can be no doubt that the State has 

the right to do this just as it frames regulations with respect to 

other dangerous manipulations. When such a regulation has 

been strictly enforced for some time the resistance to it ceases. 

The workmen regard the wearing of spectacles as something 

-quite reasonable, as e.g,^ they now do the wearing of respirators in 

<:ertain factories, &c. The means to be employed to get the 

^vorkmen to wear spectacles are : 

a. Direct order of the government compelling the proprietors 
snd directors of factories under penalty to insist on those of their 
^vorkmen for whom it is necessary wearing spectacles. 

b. The accident assurance companies in which the workmen 
insure themselves or are insured by the proprietors of the fac- 
"t cries, should not take on any workman who does not wear 
X>rotective spectacles — of course if the nature of his work re- 
<iuires them. 

I shall show hereafter how necessary it is to make the em- 



DANGEROUS TOYS. 



ployer to a certain extent pecuniarily responsible for his \ 
men's injuries. If this were the case then the employer in his ofl| 
interest would take care that the eyes of his workpeople ive 
protected, — -MAGNUS very properly says that one-eyed workma 
should not be employed in occupations which Jeopardise the eyes. 
In certain operations (puddling, hammering, stirring up the molten 
iron) when the whole face requires to be protected, a mask made 
of fine wire net might, as Layet proposes, be worn over the face. 

3. With regard to children's toys, the most dangerous soi^ 
should not be allowed to be sold. As the authorities forbid t 
sale of toys painted with poisonous colours, so they are entitled J 
do the same with regard to toys dangerous in other ways. 
these belong in especial such as consist in part of explosive p|l 
parations, like percussion pistols, pea-shooters, and the like, i 
also sharp pointed missiles for cross-bows or blow-tubes. 

4. In many cases of severe injury the eye may be savedfl 
medical aid is obtained in time. In recent times Iheemployme^ 
of the magnet has extended the range of such cases. On t 
other hand many injuries to the eye which arc comparativi 
slight cause the eye to be lost if the}^ are neglected. The ma] 
tenance of the injured eye in a condition where the sight is j 
served and inflammation warded off is the best protection ag^H 
sympathetic ophthalmia of the other eye. Therefore 
great importance that the injured workman should at on 
to medical aid and remain as long as necessary under treatment 
In large manufactories there is usually an appointed medical 
man. When there is no appointed medical man, the workpeople 
must apply to some otJicr doctor who maj' live at a distance frd 



SYMPATHETIC OPHTHALMIA. 1 87 



the factory. In either case the workman will often refrain from 
resorting to the doctor for fear he might lose his wages if he dis- 
continued his work. This is all the more likely to happen should 
the workman be required to abstain from work for a considerable 
time for medical treatment. He runs the risk of subjecting his. 
family to privation and hunger. 

The withholding of the workmen's wages in such cases is done 
in various manners according to local conditions. In the larger 
establishments a certain proportion of the wages (usually one- 
half) is paid to the sick workman for a certain time. In other 
cases this is done by a sick fund to which the workman is affiliated.. 
But very often neither of these methods exists ; thus employers* 
of labour on a small scale often pay no wages from the day on; 
which . the workman is injured and unable to work. Hence it 
happens that the workman goes on working in spite of his injury 
as long as he can, and thus exposes his eye to the greatest risks* 
In this there lies a great social evil ; this is diminished if the work- 
man IS a voluntary member of sick and benefit societies, but this 
cioes not entirely do away with the evil. Here it seems to me tho 
interposition of the law is required, either by compulsory insurance 
^.gainst accidents, or by making the employer responsible foK 
injuries to his workmen, as is practised in some states. 

Sympathetic ophthalmia is amenable to prophylaxis if taken; 
in time, more than any other disease ; enucleation of the injured 
^3'e as long as the other eye is perfectly sound, secures almost 
absolute protection. No doubt sympathetic ophthalmia some- 
times comes on only after enucleation, but this is an extremely 
^are event. I have only met with fourteen such cases in medical 



i88 ENUCLEATION OF THE EYE. 

literature.* The sympathetic inflammation occurred in these on 
the second to the thirty-fifth day after enucleation, but all these 
cases recovered with two exceptions. Thus they were of a very 
mild character, so that even in them the good influence of enu- 
cleation was manifest. 

Enucleation is easily performed, so that every practical surgeon 
can undertake it. This alone is a strong reason for preferring it 
to other operations more difficult of performance, such as neuro- 
tomia optico-ciliaris. Another reason for preferring enucleation 
is that the last-named operation even when well performed does 
not secure the perfect protection that it would seem to do from 
the published accounts of some cases.t Therefore enucleation 
should be performed in all cases where the injured eye has lost 
the sight or will inevitably do so, and where the possibility of a 
subsequent sympathetic inflammation of the other eye is to be 
apprehended. English surgeons are often reproached by their 
continental colleagues with resorting too soon to enucleation. 
This reproach is unjust ; it is always better to remove a blind eye 
which might have been retained, than to allow a sympatheti 
ophthalmia to occur which might have been avoided. — Unfortu 
nately the proposal to enucleate his eye too often meets wi 
opposition from the patient. The extension of general cultun 
among the public will render them more amenable to the reason 
given by the surgeon. 



* These are recorded by Snell, Critchett, Nettleship, Muelli 

COLSMANN, PaGENSTECHER, SCHMIDT, BRUDENELL CARTER, FROST ^ 

Steinheim. 

Leber, Poncet. 



i 



Part VI I. 



Qfluence of Social Conditions on Eye- 
diseases. 

§ 62. Eye diseases, like so many other diseases, are the 
>ecial scourge of poverty. There are, it is true, no statistics 
hich divide eye patients into poor and rich, but a glance at the 
)hthalmic dispensaries of large towns will afford convincing 
oofs of the truth of what we say. Ignorance goes hand-in- 
ind with poverty. The statistics of blindness show that under 
herwise identical conditions, the poorer and more ignorant a 
ipulation is the more blind persons are met with. SORMANI 
und a strikingly large number of blind persons in the southern 
evinces of Italy, in which over 70 °/^ of the military conscripts 
m neither read nor write.* A similar state of things has been 
.own to prevail in Spain and Finland. But it is most strikingly 
anifest in Prussia. On an average there are in Prussia, 8.3 
ind persons in 10,000 inhabitants, and the proportion rises in 
)me provinces to 9 and 10 blind persons. On the other hand 
erlin has much the smallest proportion, namely, 6,6 blind to 
5,000 inhabitants, although the presence of a blind educational 
stitution draws a number of blind persons from the country to 
e town. 

* Geografia nosologica deli' Italia. Roma, 1881. 



igo 1XFLUKNCI-: of culture. 



In the following remarks I enumerate some points bearing 
on social relations which influence the health of the eyes. I 
must limit myself to a few indications, as a thorough elucidation 
of these important national economical questions would greatly 
overstep the limits of this treatise. 

I. Tlie degree of culture of the people has a great influence 
on the opportune treatment of eye diseases. An ignorant person 
-either neglects his disease entirely, or attempts to cure himself 
by the employment of domestic remedies recommended to him 
by some old woman or quack. In addition to this is a truly 
superstitious dread of every operation which we meet with in 
many uneducated people, so that they would sooner lose their 
sight than submit to the slightest operation. This is much more 
seldom met w4th among the educated classes. Statistics show 
that with the increase of general cultivation, the number of eye 
diseases increases but that of the blind diminishes. The former 
is only apparent ; those affected with eye diseases resort to the 
eye clinics more readily, hence the increase of the number of 
patients in all dispensaries, although the number of the latter 
always goes on increasing. The decrease of the number of blind 
may be illustrated by the following two examples. In England 



for every million inhabitants there were — 


In 1851 


1020 blind 


„ 1861 


• •• ••• ••• ••• y^v/i^ ^* 


„ 1871 


• •• ••> ••• ••• ^7^ ^ 1) 


„ 1881 


• •• ••• ••• ••• ^/ J7 1) 



In Prussia the number of the blind from 1871 to iSSo 
became smaller by 1.3 ^\^^ whilst at the same time the population 



CLEANLINESS — ALIMENTATION. I9I 

had increased by 10.6 °l^. Similar proportions occurred in 
•some other countries. 

I have no hesitation in ascribing this favourable alteration of 
the proportion of the blind in great degree to the increasing 
extension of education among the people. 

2. Cleanliness stands in very close relation to general culture. 
The influence of cleanliness on the spread of infectious diseases, 
as for instance trachoma, and on the occurrence of catarrhal and 
scrofulous eye affections need not be dwelt upon. 

3. The alimentation of the people becomes better and more 
rational as their prosperity increases. In consequence the num- 
ber of scrofulous children diminishes considerably. I may 
mention also those cases of chronic iridochorioiditis, which are 
especially common among ill-nourished elderly people {e,g,^ the 
poor Silesian w^eavers — v. Arlt). 

4. As regards work^ I shall only here allude to the employ- 
ment of children in factories. Besides the great harm that 
factory work entails on the physical and mental development of 
-children, it should be remembered that children are more 
liable to injuries of all sorts (also of the eyes) than adults (see 
page 179). — Various legislatures have already considered this 

-question and enacted regulations for the employment of children, 

-Some of which fix the age at which they may be employed, 

thers the number of hours of work. The age varies between 

10 and 14 years. In Switzerland the legal age is 14 years, in 

Germany, France, Holland, Sweden and Norway 12 years, in 

Hungary 12 and 10 years, in Austria and Denmark 10 years, 

in England 10 and 8 years. From the 13th to the i8th year. 



HABITATIONS—LIGHTING. 



the daily working time should not exceed eight hours. Childli 
should never be employed in night-work, or in certain cspecia] 
dangerous or unhealthy occupations. 

5. The liabitatioH has the greatest influence on the healtl 
How often is it seen that previously healthy children incij 
scrofulous affections, especially of the eyes, when they are trai 
ferred to a damp dwelling place. Smoke and foul air dispose 
to maladies of the conjunctiva: crowded dwellings promote the 
spread of trachoma. Badly lighted dwelling rooms and work- 
shops favour the production of short-sightedness. As men 
advance in prosperity and culture, their requirements in respect 
to their dwelling place increase. The habitation question j 
modern times has entered on the path of progress. To 1 
belong the hygienic conditions of a good habitation, the framiii 
of necessary regulations for the inhabited -house police, constnj 
tion of work-houses, &c, 

§ 63. — 6. Lighting. — I need not waste words upon the iiJ 
portance of lighting for the eyes. It is evident that in evf 
way daylight is the best kind of illumination. But in spite i 
this we often find work-places underground, where artiRcij 
light must be used all day. The same may be said of r 
magazines and offices, the few windows of which look on a sm 
court-yard, so that the cmploj'cs have to work for some houq 
by inadequate daylight, but the greater part of the day by arfc 
ficial light. These conditions are in large towns unfortunate^ 
too frequent, so that well-lighted offices are almost exceptioi 
Not unfrequently, indeed, it is the public offices which in thls^ 
respect set a bad example to private bureaux. The same dis- 



BRIGHTIfESS. — DAZZLING. 



193 



advantages are frequently found in shops, as also in the smaller 
work-rooms. The first requirement is plentiful and well dis- 
tributed daylight. In such places the same rules are applicable 
as for the lighting of schools {§ 14). 

kin artificial lighting what is required is sufficient light, 
proper distribution of it. The following points should be 
attended to : 

a. Brightness. — As regards this, the requirements arc the 
same as those I have mentioned as applicable to the daylight 
illumination of school-rooms. We may accept COHN'S* standard 
of brightness, viz., that the healthy eye should be able to read 
fine print {^Snelkn 0.5) comfortably at 20 inches. CoiIN thinks 
that this corresponds to an illumination of 12 normal candles or 
a little more. — We need have no fear of too bright an illumina- 
tion ; in the employment of artificial light it is not to be dreaded, 
provided that the dazzling light source itself does not fall directly 
on the eyes. 

All the methods of illumination at present in use are 
capable of furnishing adequate brightness. Which of them is 
to be preferred in special cases depends on their other advan- 
tages or defects, which will appear in our consideration of 
the other points. 

b. Dazzling. — As already stated, artificial light is only daz- 
zlitig when its source throws its image directly on the retina. 
The numerous gas jets of a theatre, the chandelier of a room, 
&c., may dazzle and fatigue the eye. The dazzling is most 

• Zeknte Versaminhing des ikutschert Vtrdiu fiir offtntliche Gemndheits- 
pflege. Berlin, 1883, p. gi. 

:3 



194 



intense in the case of the electric arc-Hght, when looked 
directly. NODIER * RocKLlFFf and Emrys JonesJ have si 
cases where violent inflammations of the conjunctiva have been 
caused in this way, but went off without injury to the eye. 
In al! cases the subjects were persons who had to set a-goii 
the electric illumination. They were in very close proximify 
the source of the light, but had neglected to put on dark pro- 
tective glasses. If these are worn and some caution exercised, 
such accidents might easily be avoided. I myself observed 
following in a case in Vienna, A cobbler's apprentice 
to a circus performance and while there fixed his eyes for 
long time on one of the electric suns placed in the roof, 
one eye he got a central scotoma, which never afterwards di 
pearcd. This case is analogous to those caused by dazzlii 
from direct sunlight (looking at the sun during eclipses), 
described by SuLZER, Haab, Haltenhoff, Deutschm. 
and others. 

In order to avoid dazzling, the source of the light may be tem- 
pered by means of ground glass in the form of globes, saucers, 
&c. These arrangements certainly cause a great loss of light 
Ordinary milk glass globes weaken the light by from 33 to 60%, 
ground-glass lamp saucers by 60% (HARTLEY). For very bright 
light like the electric light, the dimming by means of ground 
glass is not always sufficient. In such cases it is best to with- 



ye. 



' Sur una ophthalmie c. 



'e par In lumiire I'kcMgue, Th&se de Paris, 



t The Ophthalmic Review, September, iBi 
t Ibid, April, 1883. 



STEADINESS, COLOUR OF THE LIGHT. I95 

draw the source of light completely from the sight. Indirect 
illumination of this sort is applicable not only to the electric 
light (technical school of Liege) but also to gas illumination 
(House of Parliament in Berlin) and is very grateful to the eye. 

c. Steadiness of the light, — The flame should not flicker. 
Working by a flickering light is extremely disagreeable and 
fatiguing. Oil and petroleum lamps do not flicker. Open 
gas jets always flicker (the bat's-wing jet most of all) ; they 
should therefore be banished entirely from places where they 
might be used for working by. For this object argand burners 
with glass or mica chimneys are required. Even with this ar- 
rangement flickering sometimes occurs, but its cause lies in some 
derangement of the pipes (especially in winter), and it may 
generally be easily remedied. Electric lights also often flicker, 
but improved construction produces steady electric light as the 
Health Exhibitions in Berlin and London proved. 

d. Colour of the light, — All artificial methods of lighting give 
light which contains more long- wave rays than does daylight, 
consequently they have a yellowish tinge. This is the case even 
^th the electric light, which, when contrasted with gaslight, ap- 
pears bluish ; but when contrasted with daylight looks pale straw- 
<:oloured (Kruess, Meyer). O. E. Meyer gives the following 
<iata relative to the quantity of long-wave and short-wave rays 
in different kinds of light : — 



Electric Light 


Red. 
• « • ^ 


Green. 
I 


Blue. 
0.8 


Violet. 
I 


Petroleum ... 


- 3 


0.6 


0.2 


O.I 


vjrdo • • • • • • 


... 4 


0.4 


0.2 


O.I 



196 PRODUCTION OF HEAT BY 

Thus gas light is yellower than petroleum light ; and this, 
again, is yellower than electric light. In order to diminish the 
red and yellow rays we may employ a blue glass chimney, as 
is often done for gas lights. 

e. Production of heat, — Every flame produces not only illumi- 
nating but also dark rays (heat-rays), the latter, indeed, in exces- 
sive quantity. The production of heat is a disagreeable incident 
attending our sources of light. The heat produced by them 
makes itself sensible to us in two ways : by heating the air in 
the neighbourhood of the source of light, and by radiating heat 
which impinges directly on our head and eyes. Continuous 
work close to a hot source of light produces the sensation of burn- 
ing and dryness in the eyes, congestion to the head and head- 
ache. Fischer, Erismann and Cohn have furnished us with 
data respecting the production of heat from our sources of light. 
Fischer* calculates theoretically the quantity of heat-units 
produced by the combustion of certain substances. The quan- 
tities given are what must be burnt in order to give for one hour 
the degree of light of lOO candles. 

Electric arc-light 57 to 158 heat-units. 

„ incandescent light ... 290 to 530 

Petroleum 3,360 

Gas ••• ... ..• ... 4>^6o 

Colza oil ... ... ... 6,800 

ERiSMANN-f- measured the temperature of the air in the room 
in which he performed his experiments on illumination, and 

• lote Versammlungj &c., p. 76. 

t Zeitschrift fur Biologie XI I., p. 349. 



,} 



» 



w 



,} 



VARIOUS KINDS OF ILLUMINATION. I97 

found that it was much higher with colza oil and gas, than with 
petroleum. Cohn* ascertained the temperature from the electric 
light (Edison's lamp), and from gas light. He placed a black- 
ened thermometer at a distance of 4 inches from the light-source 
(which had always a light of 20 candles). In this way the 
radiating heat, which is of great importance, was measured. The 
relation between the electric light and gas-light proved to be 
as I to 2. Therefore, gas-light gives out twice as much heat 
as the incandescent electric light. — From all these experiments 
we infer that of the sources of light in common use the electric 
light radiates the least, gas-light the most heat. The produc- 
tion of heat by a gas-flame is most felt when the workman is 
compelled by the nature of his work to have the flame close to 
him, as is the case for instance with watchmakers. 

In order to avoid the heat radiation of the gas flame, it should 
be placed at a distance of 40 inches from the head. In schools, 
the gas jets should be placed 40 inches above the heads of the 
students. When it is necessary to have the source of light close, 
the electric light or petroleum is preferable to gas-light. Both for 
petroleum and gas-light, the hygienic normal lamp of Schuster 
and Bar may be recommended. Its peculiarity is that round the 
ordinary chimney a second one of larger calibre is placed ; the 
air between the two is constantly renewed by the rising of the 
heated air. With this lamp the radiation of heat is diminished 
by about i"* (Cohn, Fischer). 

f. As regards the direction whence the light falls, it is gene- 

* loie Versammlung, &c. 



DETERIORATION OF THE AIR BY THE 



rally best when the light comes from above, front and left. 
For many occupations another direction of the light is more 
suitable. Thus, for reading, it is very agreeable when the light 
comes from the side and behind. The short-sighted should 
place themselves for reading sideways at the tabic, and hold the 
book upright in the hand ; the lamp should stand at the side, 
and a little behind the head. In this way the light and 
radiating heat of the lamp would not impinge directly on 
eye. 

In order to answer the question ; what material for produ< 
the light is to be preferred ? some points must be considered, nol 
directly affecting the eye, but of importance in determining the 
choice of the kind of light. I allude to the deterioration of 
the air by the products of combustion, but chiefly to the cost 
the lighting, 

£. Deterioration of t!i£ air by the products of combusti 
These are divided into products of perfect combustion, and of im- 
perfect combustion. The former are carbonic acid and water, the 
latter carbonic oxide and hydrocarbons. The latter are evolved 
in larger quantities the less perfectly the flame is regulated by 
the supply of burning material and air in proper proportions. 
The flame smokes and the products of combustion announce 
their presence by their disagreeable smell. In well-regulated 
flames there are present only traces of the procJucts of imperfect 
combustion (Fischer.) The following table gives the results of 
some investigations made with a view to determine the quantity 
of carbonic acid produced in combustion. The quantity of car- 
bonic acid evolved by petroleum is taken as i, and from this 



Jl 



PRODUCTS OF COMBUSTION. I99 

the unit the proportion for gas and colza oil is calculated. The 
first column gives the quantity of carbonic acid ascertained by 
Erismann by calculation. The results of ZOCH* and FISCHER 
were obtained by measurement. 

Carbonic Acid evolved ctccording to 
From Petroleum 



» 



Gas . . . 



Erismann 


ZOCH 


Fischer 


I 


I 


I 


1.9 


1.2 


I 


1.4 


0.8 


2.3 



„ Colza Oil ••• 

Experimentally, Erismann convinced himself that the pro- 
ducts of imperfect combustion of petroleum, gas and colza oil 
were in the following proportions i, 4, 4. 

The electric light causes no pollution of the air; of the 
other illuminating materials, petroleum seems to be the best in 
this respect. 

h. Cost of lighting, — This varies naturally according to the 
market price of the illuminating materials. As yet we have no 
certain data respecting the cost of electric illumination. The 
following data of FISCHER and Erismann are only approxi- 
mative. In the subjoined table, I have taken the price of petro- 
leum for a certain intensity of light as the unit : — 

Kind of light. Fischer Erismann 

Electric arc-light i to 24 

„ incandescent light 3 

Petroleum i ... i 

Colza oil ... ... ... 13*4 •*• 2.6 

Paraffin (stearin) 28 ... 11 

* Zeitschrift JUr Biologie. Bd. III., p. 117. 



2<X) COMPARATIVE COST OF DIFFERENT LIGHTS. 

Although the estimates of these two investigations difTer great- 
ly, still it appears from them : I. That candles are so dear that 
they cannot be thought of as the illuminating material on a large 
scale. Consequently in my remarks on the other points I have 
omitted all consideration of them. 2. That petroleum is much 
the cheapest of all illuminating materials. 

The following conclusions are deducible from what has just 
been said regarding lighting : From a hygienic standpoint the 
electric light must be regarded as the best, provided a proper 
construction of the apparatus shall secure the necessary steadi- 
ness of the light, and that when the intensity of the light is great 
its source shall be concealed from the eye. 

By the electric light the air is neither polluted nor heated. 
The illumination is so excellent that the acuteness of vision is 
increased by ^ to ^ compared with gas. The acuteness of 
vision for colours is doubled or quadrupled (CoHN). Where the 
electric light has been employed on an extensive scale no com- 
plaints have been made of straining of the eyes (J AVAL, PONCET 
DE Cluky, Cohn) ; I can corroborate this for the Liege schools. 

The advantages of petroleum lie in the slight degree of 
yellowness of the flame, in the small development of heat, in the 
small quantity of the products of combustion and especially in 
its extreme cheapness. This last advantage allows the poorest 
workman to obtain a brilliant illumination. The disadvantage of 
petroleum lies in the care that must be bestowed on the regula- 
tion of the flame to prevent it smoking. Hence petroleum is 
ill suited for illumination on a large scale ; but for single lights it 
is the best of known illuminating materials. 



INFLUENCE OF CLIMATE. 201 

Gas possesses the advantage of great convenience in its 
management. Its disadvantages are principally the great heat it 
develops, further the pollution of the air and its relative high 
price. 



Part VIII. 



Influence of Climate and Race. 

§ 64. — I. Climate. — It is well known that in hot countries blind- 
ness is much more common than in temperate and cold countries. 
Zeune and after him Carreras-Arago endeavoured to prove 
the existence of a progressive law in^the decrease of blindness 
from south to north. According to Carreras-Arago, there 
are to every 10,000 inhabitants in Spain 11.09 blind, in Italy 
10.15, in France, 8.36, in Germany, 8.79. But then again 
there comes Norway with 13.63, and Finland with the large 
proportion of 22.45, whilst Sweden which lies between these two 
has only 8.05 blind ; so that it is impossible to establish any 
fixed law regarding it. 

Localities situated on the coast seem to have more blind 
persons than those at a distance from the sea (particularly moun- 
tainous regions). SORMANI found the maritime regions of Italy 
peculiarly rich in blind persons ; the south coast of Sicily most 
so. The same proportion in regard to the sea-coast obtains in 



202 INFLUENCE OF RACE. 



France, according to DUMONT. In Belgium also, the coast shows 
the largest quota (9.67 to 10,000) the southern hilly provinces 
the smallest (5.0 and 5.16). As regards hilly countries, Swit- 
zerland has a remarkably small proportion of blind (7.61), whilst 
the equally hilly Norway possesses a very large proportion of 

blind (13.63). 

What are the climatic peculiarities in the several countries 
which influence the production of blindness, is not yet known for 
certain. As regards hot countries, the glaring sunlight, the dust 
and the dryness of the air (North Africa) are blamed ; as regards 
coast localities the opposite condition of humidity of the air. 
Trachoma, which, more than all other ey« diseases (except diph- 
theria) has an unequal geographical distribution, prevails as 
much in hot and dry countries (Egypt, Arabia) as in cool and 
moist countries (Belgium, Ireland). 

The influence of the season of the year on many diseases, 
such as conjunctival catarrh, hemeralopia, &c., is indubitable. 
As to the more serious diseases, which alone concern us here, no- 
thing certain has as yet been ascertained. Only as regards abscess 
of the cornea it is known that it occurs principally in hot seasons 
of the year. 

2. Race. — When on the subject of trachoma I mentioned that 
in estimating the influence of race on eye diseases, great caution 
must be exercised. The degree of culture and the mode of living 
of a people is as a rule of more consequence than the race. In 
uncivilized or little civilized peoples, want of cleanliness favours 
the rapid spread of infectious diseases, and defective treatment of 
serious diseases of the eye more frequently leads to blindness. 



TREATMENT OF EYE DISEASES. 203 

I can only point to the frequent occurrence of glaucoma 
among the Jews as an established social peculiarity. According 
to Rydel * among the patients of V. Arlt*S clinic in Vienna 
the Jews furnish nearly 23 % of glaucoma whereas they constitute 
only iiiVo of all the patients. According to my experience in 
the same clinic, this is especially the case as regards inflammatory 
glaucoma. WAGNER,t of Odessa, had among nearly 20,000 eye 
patients one half Christians and one half Jews. Among the 
former there were 155 cases of glaucoma, among the latter 255 
— ^The immunity of negroes from trachoma testified to by SwAN 
Burnett and Knapp requires further corroboration; the negroes 
on the west coast of Africa are said to be very subject to 
trachoma. 



Part IX. 



Treatment of Eye Diseases. 

§ 65. In the preceding chapters we have seen that in many 
dangerous eye diseases a calamitous result may be prevented if 
treatment is resorted to in good time. Improper treatment or 
want of treatment is greatly to blame for the frequency of blind- 
ness among the less civilized peoples. In order to combat blind- 

♦ Bericht uber die Wiener Augenklinik von \, A.'KUi:, 1867. 
t V. Graefe's Archiv^ Vol. XXIX., part i, p. 143. 



204 INSTRUCTION OF THE PEOPLE 

ness effectually it is above all things necessary to provide the 
possibility of judicious treatment for every case of eye-disease. 
For this many and well-educated doctors are required. But the 
public must be instructed to apply for treatment at the right time 
and the right place. An educated person affected with an eye 
disease does not put off his application for medical aid until it is 
too late. Nor does he so readily fall into the hands of quacks as 
the uneducated. Many countries have special laws against these 
latter. But they have never been able to suppress quackery to 
any extent. Hence these laws have been repealed in Germany, 
and it is considered sufficient to make them responsible for any 
injury caused by improper treatment. The most efficacious 
remedy for quackery is the enlightenment of the people. 

The education of the people has hitherto been completely 
neglected on one point, namely hygiene. No one will deny tliat 
a knowledge of the fundamental principles of hygiene are of the 
greatest consequence for all who would preserve their health. 
Hitherto instruction in hygiene has been so badly provided for, 
that not all universities possess even a chair of hygiene where 
regular lectures are given on this subject. A very little has re- 
cently been done for the spread of hygienic information in wider 
circles. The efforts made in this direction in England are prin- 
cipally made by some societies. The National Association for 
the Promotion of Social Science, the Ladies' Sanitary Associa- 
tion, and quite recently, the Society for the Prevention of Blind- 
ness deserve especial mention. By the circulation of popular 
writings and by lectures they endeavour to spread enlighten- 
ment on all hygienic questions. In North America cheap alma- 



IN HYGIENE BY POPULAR BOOKS. 205 

« 

nacs are published, which, besides the usual information, contain 
popular information on hygienic subjects. The same is done 
in Italy at C0RRADI*S suggestion (Almanacco igienico of 
Mantegazza). But hitherto it is only in France that regular in- 
struction of the people in hygiene has been introduced, and this 
has been done in the primary and normal schools, in the lyceums 
and the agricultural schools.* It would be well if other coun- 
tries were to follow this example. 

In addition to instruction in general hygiene, it would be of 
the greatest use to enlighten the people respecting certain impor- 
tant eye diseases which might be avoided by care. To these' 
belong the blennorrhoea of new-born infants, trachoma, school- 
myopia, injuries, &c. The means of spreading such instruc- 
tion are public lectures, and particularly pamphlets written in 
popular language, which appeal to a much larger public than the 
lectures. Oculists of repute such as Beer, Adams, von Arlt, 
and others have not disdained to write such pamphlets. I have 
already alluded to the writings of ROTH, published by the 
Society for the Prevention of Blindness. COHN's important 
work on the Hygiene of the Eyes in Schools is so far popular in 
character that it is addressed not to physicians but to school 
authorities. 

§ 66, Let us now turn to medical ^nen^ in so far as they are 
concerned in the treatment of eye diseases. 

As regards medical practitioners in general, the chief thing 

* Besides these, lectures on hygiene have been delivered in the normal 
schools (schools of preceptors) in Belgium and England (see C A STELLA and 
ROTH, IV, Congrh internat, d^ Hygiene^ T. II.) 



206 WANT OF MEDICAL MEN. 

required of them is that they should always be able to be found 
when wanted ; with this is conjoined, for our purpose, the second 
requisite, that medical practitioners should be adequately sup- 
plied with a knowledge of ophthalmic therapeutics. 

As regards the first point, the most civilised countries show 
localities where there is a sensible insufficiency in the supply of 
doctors. On the other hand, there is in other localities, particu- 
larly in the towns, a superfluity of medical men. This unequal 
distribution, which is owing to the conditions of private practice, 
cannot be prevented. But surely it is the duty of the State to 
provide medical practitioners for places where they are wanted. 
Medical men who settle down in certain (po^O districts should 
receive an allowance to render their existence possible. This is 
the only way to do in sparsely populated countries. In Norway 
and Sweden the appointment of medical practitioners paid by the 
State is carried out on an extensive scale to the great advantage 
of the people. 

The second requisite I have mentioned is that medical prac- 
titioners should have an adequate knowledge of ophthalmic 
therapeutics. Every oculist knows from his own experience 
what sad deficiences there still are in this respect. 

What are the requirements of the medical practitioner in 
regard to ophthalmic medicine? He must, first of all, be able to 
diagnose and to treat correctly the slighter eye diseases ; as he 
ought not to require his patient to undertake a perhaps long 
journey to an oculist for such trifles. He must also be able to treat 
those serious diseases of an acute character which require rapid 
help. We do not expect from the ordinary practitioner the 



CLINICAL INSTRUCTION IN OPHTHALMOLOGY. 20/ 

diagnosis of the more difficult ophthalmoscopic cases, or of de- 
fects of refraction, nor yet the performance of the greater opera- 
tions. When on the subject of clinical instruction, I shall enter 
more in detail on those points of ophthalmic medicine which 
seem to me to be of most importance for the practitioner. 

In order that medical practitioners should be sufficiently in- 
structed in ophthalmic medicine, there should be well organised 
clinical instruction in ophthalmic medicine at the university, 
and a knowledge of this subject should be obligatory for the 
examinations. 

In 1870, the teachers of ophthalmic medicine belonging to 
the South German universities met at Stuttgart and formu- 
lated the following requirements : 

1. Every medical practitioner should be theoretically and 
practically instructed in ophthalmic medicine to the same 
degree as he is in all other departments of medicine. 

2. Every university should offer adequate opportunities for 
ophthalmological studies, 

3. For appropriate opthalmological university instruction, a 
special teacher, who is himself a practical oculist, should be 
appointed. 

4. The teachers of ophthalmic medicine should have the same 
privileges as other clinical teachers. 

5. There should be a public hospital and dispensary for eye 
patients, with the museums and apparatus required for instruc- 
tion. 

6. Attendance at the ophthalmological clinics and lectures 
should be made obligatory, where attendance at other medical 
lectures and clinics are obligatory. 



20S 



OPHTHALMOLOGICAL KNOWLEDGE 



7. In all medical examinations, a special section should tj 
devoted to theoretical and practical ophthalmic medicine. 

8. A practical ophthalmologist should conduct the exam 
inations on that subject. 

To these proposals I would add this one : The professor of 
ophthalmic medicine should be an ordinary professor, in order 
that his position should be quite on a par witli that of the othi 
professors. 

The minimum of time devoted to the study ofophthaira 
medicine should be six hours per week during one semester, e 
four hours per week for a whole year. The former can be don( 
in hospitals with a great supply of material, the latter (a whol^ 
year of study) in smaller hospitals, where al! the cases required for 
instruction are not always met with in one semester. The most 
important side of the instruction is the practical one. Students 
must be exercised in the examination of patients and in thH 
diagnosis of disease. Opportunities should be afforded them ^H 
learn practically certain operations, such as everting and cautef^ 
izing the eyelids, removing foreign bodies, sounding the nasal duct, 
&c. To meet tlie requirements ofthe practitioner, the inflamma- 
tory diseases especially should be studied thoroughly and on as 
many patients as possible. Not only diseases of the conjunc- 
tiva and cornea should be accurately known by the students, but 
also the inflammations of deeper seated pails. How often does 
it happen that the practitioner mistakes iritis and iridocycUtjj 
for catarrh and treats them with solutions of lunar caustic ; hoj 
often does he instil atropia into the eye in cases of glauconi 
Great attention should also be given to injuries and thqf 
treatment. 



REQUIRED BY MEDICAL MEN. 209 

Students should also be instructed in the employment of the 
ophthalmoscope, so that they may be able to diagnose slight cases 
so that they may not, for example, confound glaucoma simplex 
with cataract, as so often happens). They should also go through 
a course of operations on the dead subject. Most practitioners 
will not in practice require to perform any operations on the eye. 
But the practice of operations on the cadaver gives the student a 
certain amount of manual dexterity and, at the same time deli- 
cacy in his movements which will prove of great service to him 
in small manipulations, such as the removal of foreign bodies, 
&c. Moreover, in his quality of medical practitioner, he will 
often enough be placed in a position to determine if an operation 
is necessary or possible, in which case he would eventually hand 
the patient over to a specialist. But for this he must know 
from his own examination not only the indications for the 
operation, but also the technicalities of the operation itself. 

As regards anomalies of refraction we should, in my opinion, 
limit ourselves to teaching students the most important points, 
but not attempt to give them a thorough knowledge of 
them. In the courses of lectures on refraction which I deli- 
vered for a series of years, I became convinced that it is ex- 
tremely difficult to teach students the anomalies of refraction. 
In a course lasting several months, and with frequent practice on 
patients, we may succeed in teaching the most gifted of the 
students how to test the refraction successfully ; but for the 
great majority this department remains a sealed book. I believe 
that the time spent on this subject might be employed much 
more usefully on other important points of ophthalmic medi- 
14 



OPIITHALMOLOGICAL INSTRUCTION GIVEN 



cine. Moreover, we can hardly expect that the young pract 
tioner, who must in any case provide himself with a pret| 
extensive supply of instruments, will also purchase a compIe( 
set of lenses. 

In the examinations of the candidate for the medical degrd 
ophthalmic medicine should be the subject of a theoretical i 
practical examination. In the latter, besides showing his know- 
ledge of cases of disease brought before him, he should be 
required to make an ophthalmoscopic examination or perform' 
an operation on the dead body. 

Let us now see what provision the different States of Eurof 
have made for the instruction of medical students in ophthalml 
medicine. 

The foremost place of all the States in this respect belonj 
to Austria. In 1776 Maria Teresa appointed Earth profes 
of anatomy and ophthalmologj'. In 1813 a special chair 1 
ophthalmology with clinic attached was established 
general hospital, and Beer was nominated extraordinary pi 
fessor. This is the first independent professoriate of ophthald 
medicine. Until then ophthalmic medicine was only taught 
a sort of incidental thing by surgeons, sometimes also 1 
anatomists, physiologists or hospital physicians. In mfl 
countries it retained this dependent position until not verj- lor 
since ; in some it still retains this position. 

In 1819 Beer was promoted to the position of ordina 
professor. Since then ophthalmic medicine constitutes a subje 
of examination in the exatnina rigorosa* Now in all Austri 



'■ This, : 



; also many of !he folloiving data, is taken from BiLUK 



IN AUSTRIA, IN GERMANY. 211 



universities which have a medical faculty, viz., in Vienna, Prague, 
GraZy Innsbruck, Cracow, Pesth and Klausenburg, there are 
ordinary professorships of ophthalmic medicine. Students are 
required to take this subject for six months at least, and to 
devote one hour daily to the hospital and one hour to the lecture. 
The lecture hour usually includes witnessing the treatment of 
out-patients in presence of the students. 

Examination in ophthalmology forms a part of the third 
rigorosum (examination for the degree). It is a combination of 
theoretical and practical examination (both oral only). The 
practical examination consists in examining and describing a 
case of eye disease, and in performing an operation on the dead 
subject. 

In Germany the first ophthalmic hospital was opened in 

Leipzic in 1820. Wiirzburg followed in 1840, Gottingen in 

1847, Munich in 1859, Halle in 1864, Heidelberg and Berlin in 

1865, &c. At first the professors had to lecture on other subjects 

besides ophthalmology. Since Jena — the last among the German 

universities to do so — created a special chair of ophthalmology, 

all the universities have established independent chairs for this 

subject. The teachers of ophthalmic medicine are all ordinary 

professors. The time devoted to ophthalmic studies varies in the 

different universities. Clinical instruction is given on an average 

three or four times a week for an hour at a time, and for two 

sessions of six months (the minimum is 2, the maximum 6 

hours per week). In addition to this in some universities 

there are from 3 to 6 hours weekly of dispensary practice. 

(Ueber dcLS Lehren und Lernen an den Universitdten der deutschen Nation^ 
Wien, 1876). 



212 OPHTHALMOLOGICAL INSTRUCTION GIVEN 

Theoretical lectures on ophthalmology occupy up to 5 hours 
per week. They usually last only one semester, whilst in the 
second semester lectures are given on some select points of 
ophthalmic practice, but these are not obligatory. This in- 
struction is further complemented by practical lessons in 
operations and the use of the ophthalmoscope, as also by lec- 
tures on the anomalies of refraction. 

Since 1869 ophthalmology is a subject of examination in the 
State examination. The candidate is required to examine and 
give the morbid history of a case. He is not by law obliged to 
show his proficiency in operating. 

Switzerland has eye clinics in all its universities. That of 
Bern is indeed one of the oldest of these (1834). In the German 
universities of Switzerland the teachers of ophthalmology are all 
ordinary professors. The eye clinic occupies from three to six 
hours per week. In addition there are, as in Germany, 
theoretical lectures on ophthalmic medicine and special courses. 
In the Geneva university ophthalmology is taught by extra- 
academical teachers. Clinical instruction is given twice a week, 
(by one of the teachers only once a week) during the whole year ; 
there are besides theoretical lectures and classes for the 
ophthalmoscope. The examinations for the degree are different 
in the different Swiss universities. The State examination 
which is required in order to obtain the venia practicandi in the 
cantons united by the concordat,* includes an examination in 
ophthalmology. 

* In 1867 most of the northern cantons joined together in an agreement 
to allow free practice to one another's medical practitioners. 



IN SWITZERLAND, IN FRANCE, IN BELGIUM. 213 

In FrancBy by a law of the 14th August, 1862, the so-called 
x:ours complbnentaires cliniques were called into existence. To 
these were appointed, not professors, but midecins des Mpitatix or 
agf^gis. It was not till 1879 that a professor of ophthalmology 
was appointed in Paris. The present state of ophthalmological 
instruction is as follows : — Of the three State universities, Paris, 
Nanc}' and Montpelier, only the two former have lectures on 
ophthalmic medicine. Lectures are also given in the free Uni- 
versity of Lille. Besides the universities, medicine is also taught 
in the academies {Jaculth de ^tnidecine and koles priparatoires). 
Of these Marseilles, Bordeaux, Lille, Lyons, Tours, and Nantes 
have ophthalmological lectures or clinical teaching. The others 
(Algiers, Besan9on, Caen, Clermont, Dijon, Arras, Amiens, 
Grenoble, Poitiers, Limoges, Rennes, Angers and Toulouse) are 
still without ophthalmological instruction.* 

The time devoted to ophthalmic medicine in most of these 
schools is very limited. In Paris, for the session 1883-4, no 
lectures are announced, only clinical teaching (JProgr^s Medical^ 
1883, No. 45), &c. The same is the case in the other schools. 
The only exception is Bordeaux, where, during the winter season 
i88l-2, lectures for three hours per week were delivered. 

Attendance on the eye-clinic and the lectures on ophthal- 
mology is not obligatory, and is not a subject of examination. 
In the regulations for the examination, ophthalmology is not 
mentioned. 

In Belgium it is only quite recently that independent eye- 



* Annuaire des cours de P enseignement superieur^ 1882-3. Paris, 1883. 



214 



OPHTHALMOLQGICAL INSTRUCTION GIVEN 



clinics and lectures have been established in all the universities. 
In Liege, Ghent and Louvain, clinical instruction and lectures 
occupy three Hour a week, during two semesters ; in BrU: 
however, only ij^ hours a week, also during twelve mon1 
Attendance on these lectures is not required by law, but It Is 
generally given, for ophthalmology is one of the subjects of 
examination for the degree. The law, as it at present stands, 
prescribes as a subject of examination, " la pathofogie chirur^cale, 
y compris I'ophthalmologie." But, at present nowhere is the 
examination in ophthalmology conducted by the professor of 
surgery, but by the professor of ophthalmic medicine. A new law 
on university instruction is contemplated, according to whi 
ophthalmic medicine shall have at the examinations a perfecf 
independent place. 

In tlie neighbouring country of Holland there are now indl 
pendent chairs of ophthalmology in the universities (Utrech^ 
Leydcn and Groningcn.) Ophthalmic medicine is one of the- 
subjects in both the examination for the degree and that requirf 
by the State. 

In Great Britain and Ireland the organization of the sevi 
medical schools varies greatly. There are eye departmenl 
in all the large hospitals, but as a rule no regular lectures 
ophthalmology arc delivered. The examination is limited 
this, that the examiner in surgery has the right to put a question 
regarding ophthalmology to the candidate ; but only quite 
ceptionaiiy {e.g., in Dublin) is the examination on ophthalmoI 
conducted by a professor of that subject 

In March, 1879, the English oculists presented a petition 



rtures^l 
isseuH 
)nthsl^| 



law 

I 

the 

irecjj 

M 

i to~ 



IN HOLLAND, GREAT BRITAIN, DENMARK, SWEDEN, ETC. 2 1 5 

the General Council of Medical Education calling attention to 
the great neglect of the study of ophthalmology in England. 
They demanded that instruction in ophthalmology should be 
made obligatory. The report of the English medical schools on 
this petition was unfavourable to its proposals.* 

In Denmark there is in the Copenhagen University a chair of 
ophthalmology with an eye clinic, but the time allotted to the 
study of ophthalmic medicine is very short. Ophthalmology is 
not a special subject of examination for the doctor's degree. 

In Italy^ there are special chairs of ophthalmology in all 
the universities. The study is obligatory, every student being 
required to attend the instruction for two sessions of six months. 
Candidates for the degree are examined theoretically and prac- 
tically in ophthalmology. In the practical examinations the 
smaller operations are required to be performed. 

In Norway and Russia there are special eye-clinics with a 
professor of ophthalmology at the head. Ophthalmology is a 
subject of examination for the degree. 

The same is the case in Sweden^ where, however, the eye- 
clinic is united with the surgical clinic. 

In the medical school of Constantinople only theoretical lec- 
tures on ophthalmology are delivered. In Athens, there is an 
eye clinic, and candidates for the doctor's degree are examined in 
ophthalmology. 

From the above it is evident that the provision for instruc- 
tion in ophthalmology is still very indifferent. In this respect 

* HiRSCHBERG, Cetitralblatt^ 1880, p. 28. 



2l6 IMPERFECTIONS OF OPHTHALMOLOGICAL INSTRUCTION. 

Austria may be looked upon as a model for other countries. In 
every respect ophthalmology there takes its appropriate place. 
In all its universities there are independent eye clinics with ordi- 
nary professors at their head. Attendance at the lectures and 
clinical instruction is obligatory ; in all ten hours a week for a 
session of six months are devoted to it In addition to this, 
there is a course for operations, attendance on which is indirectly 
obligatory, as a practical knowledge of eye operations is required 
at the examination for the degree. The candidate is examined 
theoretically and practically in ophthalmic medicine and re- 
quired to perform an operation on the eye. All the require- 
ments above indicated as essential to ophthalmological instruc- 
tion are thus in full operation. In most other countries the time 
given to ophthalmology is shorter, the examination up#n it 
much less strict. Two large States, France and Englanc, are 
still far behind as regards ophthalmological teaching. In the 
majority of the French schools (14 out of 22) no opporturity is 
given to the student to study ophthalmology, for they possess no 
eye clinics, and no teachers of the science. In the otierS 
schools (2 universities and 6 ^coles de m^decine) there are eye 
clinics but the time allotted tp ophthalmological teaching is 
often quite insufficient (e,g. in Tours only once a week, on Sunday^ 
In the Paris University there was no chair for ophthalmologj 
before 1879. Finally, in England, there is no provisional all foi 
regular instruction in ophthalmology, and the medical authorities 
have not advanced so far as to perceive the need for such in- 
struction. Indeed, the Universities of London and Edinburgh 
declared themselves hostile to the proposal to require from candi- 



EYE DISPENSARIES. 21/ 



dates a special knowledge of ophthalmology. There remains, 
therefore still much to be done before the first and most impor- 
tant requirement is fulfilled which the prevention of blindness 
demands of us, the general possession by medical practitioners 
of a knowledge of ophthalmic medicine. 

§ 67. Eye dispensaries. — If the properly educated medical 
practitioner is capable of treating by himself many cases of ocular 
ailments, he will still have to refer the serious cases to the 
specialist. By serious cases I mean those whose diagnosis pre- 
sents some difficulties, as for instance many affections of the fundus 
of the eye, anomalies of refraction, &c., and those whose treatment 
requires special dexterity, especially cases requiring an operation. 
Most eye diseases are of such a character that they allow of the 
patient going to the doctor and even making a journey to see him. 
Therefore an oculist residing in the centre of a populous district 
may include a wide circle in his practice. Such being the facts 
an effort should be made to establish an eye dispensary under 
the direction of a specialist in every town that requires it. 
This will depend on the number of inhabitants of the town and 
of the surrounding country (district, province). In Germany 
there is generally no lack of oculists, but their distribution is 
often unequal. Whilst in many middling sized or even small 
towns there may be more resident oculists than there is room 
for, in other places there is a want of oculists. In other 
countries there is everywhere a deficiency of oculists, who, as a 
rule, are only to be found in latrge towns. To give an example 
from my own country, I may mention that the whole province of 
Moravia does not yet possess a single oculist in its capital 



Briinn, although the province is 404 square miles in extent, 
has about two million inhabitants. In the province of Up] 
Austria (218 square miles and about 8oo,cxX) inhabitants), 
in the province of Salzburg (408 square miles and over 
million inhabitants), eye dispensaries have only existed for a fe 
years. They are in a flourishing condition, thereby showing 
they were much needed. 

It is the duty of the State (or of the province or town)' 
remedy this bad state of things, and to provide for the settH 
of an oculist where one seems to be required. This cannot 
ascertained by simply reckoning the number of inhabitanl 
The chief point to be considered is the frequency of eye di 
fespecially trachoma) in the locality in question ; further, 
density of the population. In a dense population one doctor 
suffices for a proportionately lai^e number of inhabitants. 
The more sparsely the population is distributed, the smaller 
number of inhabitants that should be reckoned for the docti 
so that patients suffering from eye diseases may not have 
make too long a journey to see the doctor. It is preci 
the scantily-peopled regions, requiring a relatively large nuinl 
of oculists, which are most destitute of them, for they offer the 
young oculist no very attractive outlook for his professional 
career. If the State wishes to attract an oculist thither, it mi 
hold out to him certain advantages which will help him 
ginning practice ; and, further, the physician on his side shoulf 
undertake some duties, I shall take the liberty to indicate what 
appears to me the proper course to pursue. 

When it is ascertained that in the chief town of a district 



:ants. 
rt^J 

)Ct^| 

1 

r tht ' 
inal 



STATE TO OCULISTS WHERE REQUIRED. 219 

province it is desirable to establish an eye dispensary, and no 
one voluntarily offers to do so, the authorities should offer the 
following advantages to a physician : — 

1. The physician should be allowed to designate his dispen- 
sary as a concession by the authorities, e,g,, as a municipal or 
State dispensary, or the like. Thereby the public will have more 
confidence in the new doctor, seeing that the authorities 
guarantee to a certain extent that the doctor in charge of the 
dispensary has special qualifications as an oculist. 

2. The authorities should announce the establishment of 
this eye dispensary by frequent advertisements in official and 
other widely-circulated papers. This will obviate the necessity of 
unprofessional advertisements on the part of the doctor himself; 
it will have the effect of inducing the public to make extensive 
use of the dispensary, and will secure for the young practitioner 
a rapid introduction to a large sphere of action. 

3. The establishment of the dispensary should be facilitated 
to the doctor, e.g,^ by the contribution of a sum of money to 
enable him to procure the necessary furniture and instruments, or 
by granting him some suitable locality, or by paying the wages of 
a servant or nurse. In the case of a very poor population it would 
be right to give the doctor some pecuniary aid, which would 
allow him to give poor patients the medicines and glasses they 
require without payment. 

4. Some beds should be allotted to the doctor in the town 
hospital for patients who require to be treated in the hospital. 
If this is not practicable, some beds should be fitted up in a 
suitable locality for the use of the oculist. 



220 DUTIES OF STATE- PROVIDED OCULISTS. 

5. In certain cases it might be necessary to offer the 
oculist a salary in order to induce him to settle in remote poor 
provinces. 

It depends of course on local conditions who shall bear the 
cost of such an arrangement. Sometimes it would be borne 
by the province, sometimes by the town. Larger communities 
might, perhaps, endow a free bed in order that their dependents 
might be treated in the establishment free of charge. In the 
case of very poor places the help of the State must be invoked. 

The duties which the oculist will have to undertake are the 
following : — 

1. He must prove that he has a special and particularly a 
practical knowledge of ophthalmic medicine {e,g.^ that he has 
filled a sufficiently long time the post of assistant in an eye 
hospital). 

2. He must be at the dispensary for the purpose of seeing 
patients at a fixed hour at least every other day, and must give 
gratuitous advice to the poor. 

3. He must make a report to the superior sanitary aut^iorities 
once a year. This report should contain a statistical table of 
the patients treated ; further, it should mention the eye diseases 
especially prevalent in the province and their causes, as also the 
cases of blindness that come under his observation. 

4. The physician should undertake the examination of the 
eyes of the scholars in the middle schools of the town in 
reference to refraction.* 

* On pp. 79 and 81 I have stated that I consider an examination as to re- 
fraction only necessary for the scholars of middle schools, and once a year 



UNEQUAL DISTRIBUTION OF OCULISTS. 221 

5. The dispensary should be under the control of the chief 
sanitary authority, in order to prevent it being carried on in an 
illusory manner for the purpose of enjoying the material advan- 
tages accruing from it. 

I believe that in this way there would be no difficulty in 
attracting oculists wherever they are required. When the time 
comes that every university in all countries shall have its eye clinic, 
the assistants will furnish a sufficient number of young oculists. 
All that is required is that a certain influence should be exer- 
cised over their settlement. At present the young practitioners 
often do not know where to settle down on leaving the hospital. 
Many remain in their university town, where there is generally 
an ample supply of oculists, or they locate themselves in some 
other place where there is great competition. But if it could be 
intimated to them, as above proposed, where an oculist is wanted, 
if their settlement should be materially facilitated and provision 
made for their speedy acquisition of a sufficient clientele, this 
would prove a strong attraction for young oculists. 

In the larger towns there are, as a rule, several eye dis- 
pensaries ; but their number is often insufficient for the large 
population. They are then so over-crowded that the proper 
amount of attention cannot be given to each patient ; moreover 
they are often very unequally distributed over the different 
quarters of the town. 



sufficient. This when practicable should be done by an oculist, as the re- 
quisite knowledge cannot be expected in the school doctor. The oculist 
might undertake the examination of the scholars of the middle schools of 
neighbouring towns for a suitable honorarium. 



ORGANIZATION AND OCUI.ISTIC 



Even now in many hospitals eye patients are mixed ug 
with surgical cases and are treated along with the latter by the-1 
surgeon to the hospital, who is not as a rule specially conversant 
with ophthalmic aflections. Where this state of things obtains, 
it should be put a stop to, and a special department set aside 
for eye cases. This department should also contain separate 
rooms for infectious eye diseases, and be under the care of atiM 
oculist. I 

5 68. Organkalion of the sanitary mitliorilies. — In order 
that the prophylactic measures should be able to have their 
full influence, they should not exist merely on paper, but they 
must be practically realized. It is not sufficient that this shoul 
be done as hitherto only in model .schools, eye hospitals c 
lying-in hospitals, &c., but these measures must be carried c 
on a great scale and thoroughly. To secure this, the centrafll 
zation of the sanitary service is essential, the operations 
which all over the country should be superintended by a chief 
sanitary authority, which should have a sufficient amount of 
scientific attainments for the difficult task it has to perform. 
This task is of a twofold character: first it has to organize and 
direct the sanitary service throughout the whole country, and 
next it has to carry out scientific works connected with hygiene. 
By this I do not mean works {e-g., of an experimental kind) whi 
require a laboratory and which properly belong to the univol 
sities. The most important task of the chief sanitary authorin 
is to form a scientific appreciation of the material that flows | 
upon it in the form of reports of all kinds. These are 
intended never to be read again, but sent to moulder in 



DUTIES OF THE SANITARY AUTHORITIES. 223 



archives. But their scientific elaboration and utilization can 
only be performed by the chief sanitary authority, because it 
alone possesses them in a complete form. 

This is not the place to enumerate the manifold duties of 
the chief sanitary authority. I may, however, be permitted to 
allude to a few points specially affecting our subject, I mean the 
hygiene of the eyes. As regards this, the attention of the chief 
sanitary authority should be given particularly to the following 
points : 

1. Furnishing normal standards for educational purposes. 
These concern the construction of school buildings, school 
furniture, school-books, methods of instruction, the time devoted 
to instruction, its arrangement, &c. 

2. The appointment of committees for examining and 
reporting on the schools, ascertaining if they are suited for 
educational purposes, or what alterations they require in order to 
make them so. Drawing up a code of instructions for school- 
doctors, appointing school-doctors. 

3. The establishment of eye dispensaries where they are 
needed. The appointment of oculists to these dispensaries and 
the supervision of them. The framing of a uniform plan for the 
reports of these oculists. This is an indispensable requisite for 
their scientific appreciation. CoHN long ago called attention to 
the want of such uniform reports. He constructed a plan* 
ivhich he sent to ophthalmic hospitals and oculists, which has 
been adopted by some of them. 

* S^e^kGiEAJsJahresbericht fur Augenheilkunde, 1872. 



224 ORGANIZATION AND OCULISTIC 

4. The analytical examination of the reports furnished by 
school-doctors, oculists, &c. These supply excellent materials 
not only for purely statistical works, but also for solving scientific 
problems. Delegates or committees should be appointed for the 
special study of epidemics of eye diseases, or for the investiga- 
tion of important circumstances. 

5. Proposals for the improvement of sanitary conditions. 
Improvement of the old and introduction of new prophylactic 
measures, e.g.^ for preventing school myopia, the spread of in- 
fectious diseases, injuries to the eyes of work-people, &c. Pro- 
posals in reference to the compulsory treatment of certain 
infectious eye diseases and the duty of notification on the part 
of the physicians. An important question bearing on this point, 
is whether the parents should be made responsible when they 
neglect to take care of their children suffering from eye diseases 
and refrain from subjecting them to suitable medical treatment 

6. If the chief sanitary authority sets up a laboratory, the 
sphere of its work will thereby be considerably extended. 
This will comprise questions of general importance, such as, for 
example, the infectious character of certain eye diseases, the 
conditions of their transmission and their prevention ; the value 
of antiseptic remedies in ophthalmic medicine, &c. 

If we compare the organization of the sanitary service of 
different countries, we find that it is in general ordered according 
to three different types. 

I. Complete decentralization of the sanitary service. This 
was the rule in former times. The State troubled itself but 
little or not at all about hygiene, and left it to the several com- 



DUTIES OF THE SANITARY AUTHORITIES. 225 

munities to act as they pleased in regard to it. Holland was 
the last to abandon this organization ; until about 20 years ago 
the care of the public health was exclusively in the hands of 
the communal authorities and the superior political authorities 
could not exercise the slightest influence or control. In 
Belgium this system still prevails ; the sanitation is superintended 
in every province independently by the commission midicale of 
the province. A similar arrangement obtains in Norway. 
This system of decentralization has this disadvantage, that 
sanitation is left to the judgment and zeal of the local authorities. 
Whilst some towns or provinces enjoy very good public sani- 
tation, in others it is completely neglected. 

2, In most States the superintendence of sanitary matters 
is entrusted to a minister who performs it through his underlings. 
As a rule with the minister is associated a chief sanitary council, 
which is, however, only a consultative authority (France, 
Austria, Italy, Denmark, Russia). The sanitary council 
is composed of medical experts, hygienists, engineers, &c., but 
the minister is not bound by their decision. The actual conduct 
of sanitary matters is left to the minister's underlings who often 
are quite ignorant of the subject. The men of science who 
constitute the sanitary council, at length tire of investigating 
questions brought before them and giving their opinion res- 
pecting them, when they see that the decisions they arrive at are 
often only destined to accumulate dust in the archives of the 
ministry. 

3. The most rational organization of sanitary matters exists 
in England (and Sweden). In the English Local Government 

15 



226 OCULISTIC DUTIES OF THE SANITARY AUTHORITIES. 

Board all that is required is united under one controlling power. 
It is composed of distinguished experts. It receives all reports 
and statistics. It decides what measures are necessary, and 
sees that they are carried out. It issues directions relative to 
the appointment of the lower grades of sanitary officials. 
The parochial authorities are under its control ; it sends out 
skilled officers to investigate special nuisances. All important 
sanitary changes in the various parishes and communities must 
be approved by it before they can be carried out. It has more 
than 250 laboratories at its command, in order to detect the 
adulteration of articles of food. 

The chief sanitary authority should therefore consist of 
persons having special knowledge of sanitary subjects, and 
should at the same time have full power to set a-going those 
measures they deem necessary and to superintend their exe- 
cution. It should of course have a sufficient supply of funds at 
its disposal. 

In order that the hygiene of the eye should receive at- 
tention proportionate to its importance, it is indispensably 
necessary that an oculist should have a seat and a voice on the 
board. 



Conclusion. 



In the preceding pages I have endeavoured to show what 
measures we should adopt in order to counteract the production 
of blindness. Whether these will have the desired effect the 
future will show, for as yet only a few of them have been carried 
out to a limited extent But the experience of them already 
obtained, shows that we are able to prevent the occurrence of 
certain diseases with almost absolute certainty. I refer to the 
blennorrhoea of newborn infants. All that is needed is to carry 
out universally and strictly what all experts declare to be 
necessary. Unfortunately, we shall have to wait long before this 
is done, and many must in the meantime lose their sight which 
might have been preserved. 

Our efforts must be devoted always to take up afresh and to 
discuss the questions bearing on the prevention of blindness. 
In this way ever increasing circles will be made familiar with 
this subject. As each one is made aware of the danger he can 
the more readily protect himself from it. We must force upon 
influential circles the conviction that something must be done to 
ward off the evil. The idea that led to the establishment of the 
Society for the Prevention of Blindness is an excellent one. 
This Society keeps up a constant agitation, and thereby hastens 
the advent of the time when the State itself shall undertake the 
campaign against blindness in an efHcacious manner. 



228 CONCLUSION. 



The efforts of hygienists had formerly and, indeed, have still, 
to war against prejudice and indifference. Their proposals and 
recommendations are often enough represented as tiresome 
fussiness and sought to be frustrated. But in view of the im- 
portant results already obtained by them, they may console 
themselves. Europe is much more rarely devastated by epi- 
demics than formerly, and the average duration of the life of 
man has been considerably increased. Hygienists have so 
many and such vast problems to solve, that hitherto they have 
occupied themselves but little with the special hygiene of the 
eyes. It is only right that the oculists should lend their aid to 
fill up the lacunae left. 

On the part of the State, hitherto nothing has been done for 
the prevention of blindness (if we except some regulations foir 
schools and precautionary measures against trachoma). And ye 
the question is not merely a humanitarian one, but is a politica 
economical one of the greatest importance. The burden of th 
support of the blind falls — with few exceptions — on their seein 



fellow countrymen. This burden is by no means small. In Europ 
there is on an average one blind to every i,ooo of populatio 
which will give for all Europe 311,000 blind persons. If w 
take the daily cost of these per head at only lod., this implies 
yearly cost of above ;f 4,5 20,000. If we take for granted that 
one quarter of the blind need no pecuniary assistance, eitheiT 
because they are in easy circumstances or because they can 
earn their own living,* there still remain ;^3400,ooo. If we 



* Zehender (Klinische Monatsbldtter fur Augenheilkunde^ 1870) en- 
quired into the circumstances of the blind in the Grand Duchies of Meek- 



CONCLUSION. 229 



allow that one-third of all the blind, that is 103,666 persons, 
would earn is. 8d. per diem if they could see, that would make — 
reckoning 300 working days — ;^248o,ooo. This added to the 
cost of maintenance, involves an annual loss of ;^S,88o,ooo for 
the states of Europe. 

There is no doubt that a good prophylaxis against disease, 
a rapid and intelligent treatment of disease when already 
present, might prevent many cases of blindness. MAGNUS, 
Bremer, and Steffan are of opinion that 40'' I ^ of the cases of 
blindness might have been prevented. COHN regards blindness 
as certainly preventible in 33%, as probably preventible in 43°/o, 
and as quite unpreventible in only 24°/^^. Were we only 
successful in preventing the certainly preventible cases of blind- 
ness, then this would amount — following the least favourable 
estimate of Cohn — to one third of all the blind. There would 
be about 100,000 fewer blind persons in Europe. Who can 
measure the amount of suffering and distress connected with 
those 100,000 cases of blindness? The philanthropist can 
imagine no more worthy task than to contribute to the diminu- 
tion of this misery. The States themselves would profit thereby. 
A^ccording to the above estimate they would save more than 
£1,080,000 in the cost of maintenance of the blind. This sum 

would be more than sufficient to pay for the most extensive 

prophylactic measures. 



teabmg-Schwerin and Mecklenburg- Strelitz. He found that of 423 blind, 
106 were not assisted, whereas 3i7=J(th of all the blind — were supported. 
some by their friends, others by public funds. 



230 



CONCLUSION. 



Almost everything has still to be done in this field ; all 
must work together in order to carry on the war against 
ignorance, superstition and indifference. Hygienists and ocu- 
lists, political economists and statesmen, yea all philanthropists, 
must lend a helping hand in this work — viribus unitis. 



A! 



II. 



;/ 



w 



8 



■e 



-:—- — -r- T»3W3^?^i.k. " .". ajJ ara gy'a^ryn rM 



,/^ V '' 



f^f^^^^''^ 



Appendix No. i, by Dr. Dudgeon. 



Chronic Poisoning. 
See page 103. 

Paisoning by arsenic is a frequent cause of severe conjunctivitis, which 
not only prevents the use of the eyes temporarily while it lasts, but which, 
by repeated occurrence, may prove permanently injurious to the sight. We 
find this affection in its most severe forms in workmen employed in the 
manufacture and the hanging up of papers which are coloured with prepara- 
tions of arsenic, the chief of these being the arseniate of copper, which is 
much used for the production of a bright green colour. But other colours 
are oflen produced by arsenical compounds. Papers so coloured are often 
very injurious to the health of persons who inhabit rooms hung with them, 
and severe conjunctivitis is one of their most common effects. Muslin window 
curtains and even dresses are occasionally coloured with these poisonous 
dyes, as also the leaves of artificial flowers. In any of these situations the 
eyes may be and frequently are injured by the poison. A very proper 
subject for State interference would be the regulation of the manu- 
facture of these articles and the absolute prohibition of the use of arsenical 
colours for purposes where they may prove injurious to the health. 

The plan resorted to by some women, in order to increase the lustre of 
their eyes, of instilling into them belladonna or atropine^ is always attended by 
temporary impairment of vision by paralysing the accommodation, but the 
habit, if persisted in, may cause permanent injury to the optic nerve. It 
would be well to warn those who have recourse to such objectionable 
practices of the risks they run. 



Appendix No. 2, by Dr. Roth. 



Positions while Writing. 

See page 54. 

The idea of many oculists as well as medical men in general, that it is 
desirable to support children and students while writing, in a good position, 
by mechanical contrivances on which the forehead leans, as advised by 
Professor Fuchs and others, see fig. 5, page 54 ; or by a support, as suggested 
many years ago by the late Dr. Schreber, on which the two clavicles lean is 
entirely erroneous. 

It is desirable that persons who sit in bad positions while writing should 
lean against the back of a chair which is convex in the place corresponding 
to the lumbar part of the spine, while the upper part is concave corres- 
ponding with the convexity of the upper part of the back ; at the same time it 
is desirable that the height of the chair seat from the floor should be equal to 
the height of the leg up to the knee, the depth of the seat should be equal to 
the length of the thighs, and the height of the back of the chair should be 
equal to the length of the back from the seat to the upper part of the 
shoulders. The width of the seat must correspond to the width across the 
hips of the sitting person. It is often objected that a person placed in such 
a comfortable position on a chair, as just described, is not able to write 
comfortably ; but this is not the case, because the top of the writing table or 
a sloping writing desk is so arranged that it can be moved horizontally 
towards the body of the writer ) the writing desk is such a height that both 
elbows, or rather the forearms, are placed comfortably on it ; the paper or 
copy book is placed obliquely from the left to the right, so that the diagonal 
line should be perpendicular to the edge of the table. 

Having adopted this position for years for my patients suffering from 
curvatures and also for perfectly healthy persons, I am able to speak from 
experience that it is much better to bring the writing table to the body than 
\}oi& body to the writing table. In the position described the writer remains 
always in a natural position without twisting or leaning the body on one 
side, without bending the head forwards and sideways and without straining 
the eyes. I prefer in cases of short sight to let the writer have well chosen 



SEATS AND DESKS. 



Spectacles and thus all the disadvantages of a crooked and stooping position 
and of straining the eyes are prevented ; those who are incredulous are 
advised to try the arrangement proposed regarding the chair, the desk, and 
the paper, and they will be soon convinced that there is no more comfortable 




position to be found for the writer, and that the mechanical supports for the 
forehead or clavicles are perfectly unnecessary. The following illustrations 
wfll give a correct idea of the manner of carrying out the suggestions which 
have been just described." 

* Des^s of school furniture, &c. 



234 POSITIONS WHEN WRITING AND DRAWING. 

The illustrations 4 to 1 1 show how bad positions in writing, drawing, 
etc, can be prevented in public and private schools by encouraging the 
vn-iter always to lean back in the chair and to draw the writing table or 





F«. 4- 



Fig- S- 



desk to the body, instead of leaning forwards and bending the body towards 
and on the table. In the chair, fig. i, the height of the seat corresponds 
with the length of the legs (from foot to knee), the depth of the seat with the 




lei^th of the thighs, and the height of the back of the chair with the length 
of the body from the seat upwards. There is a moveable convex pad fittii^ 
into the lumbar curve, while the concave part of the top of the chjur penmts 



POSITIONS WHEN READING. 



the shoulders to rest ; the whole body is at rest and no efTort is required to sit 
up ; the top of the desk being moveable is brou^t close to the body, and 
there is-no necessity for stooping or leaning over the table. Figure 2 is a 




school chair and desk. Figure 3 shows how the desk and seat.can be raised or 
lowered also how the desk can be moved horizontally forwards.* Figures 4 
and 5 are instances of school boys sittinginbad positions in which the eyes are 



* I have given the drawings of my chairs lo the North of England School Furnishing 
Company, who have a depdt in Newgate street, city of London. 



236 COLOUR OF PAPER FOR BOOKS. 



unequally directed to the writing because the head is too much turned to 
one side. Figures 6 and 7 represent bad and good positions of girls while 
drawing. Figures 8 and 9, 10 and 11 represent bad and good positions 
while reading. 

These few illustrations will be sufficient for proving how bad positions 
affect the eyes and how short sight is produced ; I must refer those more 
interested in this subject to my table of injurious positions to be avoided 
during tJie period of growth and education^ published by the publishers of 
this Prize Essay. 



The Colour of the Paper. 

See page 63. 

Regarding the colour of the paper there is still a controversy going on. 
Professor Fuchs and some others advocate perfectly white paper for 
printing school books, etc., because the contrast between the perfectly white 
paper and the black letters is so great that even when the light is not very 
strong the reading is still easy. According to experiments made by Babbage 
about forty years ago, it was proved that black print on yellowish tinted 
paper is the most distinct and the least fatiguing to the eyes, and in con- 
sequence of a proposition which I made at the International Congress of 
Hygiene at Turin in 1880, and which was very much discussed, a resolution 
was passed, or rather the desire expressed, that the printing of school books 
on yellowish tinted paper should be specially recommended to the various 
governments. 

The Society of Hygiene at Lausanne also declared itself against the 
use of white paper, and they recommend a kind of bluish grey paper as 
less injurious to the eyes. 



Gymnastic Apparatus. 

See page 66. 

Lately there is a fashion prevailing to let school children practise gym- 
nastics on gymnastic apparatus ; this is not necessary. The harmonious 
development of the human body, as far as it is required for a scientific 
physical education, can be obtained by free exercises (that is exercises with- 
out the aid of any gymnastic or other apparatus), and by the various 
out-door games^ by marching, running, leaping, swimming. This is not the 
place to enter into the details of the mode of developing harmoniously all the 
parts of the body, but as long as the teachers themselves are not instructed 



SCHOOL DOCTORS. — TRACHOMA. 237 



in the elements of physical education and in the exercises required for that 
purpose, as well as in the elements of general and of school hygiene, there 
is no hope of arresting the degeneration of the physique of the population. 
Gymnastic apparatus is required only for gymnasts, firemen, soldiers, 
acrobats, etc. The expenses for gymnastic apparatus may be saved in all 
schools. 



School Doctors. 

See page 78. 

Dr. Fuchs will be surprised to hear that in Great Britain such a being as 
a school doctor does not exist. Several years ago I called the attention of 
the school authorities to this subject, and published a short pamphlet on the 
obligatory medical inspection of schools where I gave the outline of the 
excellent system of school inspection and of personal examination of each 
pupil prevailing in Brussels, which was introduced by Dr. Jansens, the 
learned chief of the Bureau cP Hygiene of the town of Brussels. My propo- 
sition was considered Utopian, and I remember that one of the hard-working 
members of the London School Board asked me privately not to speak of 
medical inspection of schools, as the tax-payers complained already about 
the high rates for education. We will hope that some intelligent M.P. will 
bring this subject before Parliament, and will prove that it is better to pay 
for medical inspection of schools and scholars, than for increased poor rates, 
hospitals and convalescent homes, and that prevention is cheaper than 
cure. 



Trachoma. 

See page 154. 

Although Dr. Fuchs twice mentions the frequency of this disease 
amongst the Dutch Jews, he does not name one of the principal causes of 
this disease amongst the Jews in Amsterdam, which Professor Snellen, of 
Utrecht, pointed out to me, viz., the bathing of Jewish women and girls in 
common tanks at the end of their monthly periods ; also of women after 
their confinement. This is a religious ceremony prescribed for the sake of 
cleanliness and hygiene. As there are many trachomatous amongst the 
bathers, and as the head is submerged in the water which contains much 
vaginal secretion of various kinds, this ceremonial bathing is a frequent 
cause of infection. 



Glossary of Technical Terms. 



Accommodation ... 

Acute diseases ... 

Adultorum 

Aegiptiaca 

Albinism 

Albuminuria 

Amaurosis 

Amblyopia 

Anaemia ' 

Anchylostomosis . 
Anopthalmus ... 
Autochthonous . . . 
Aqueous humour. 

Arthritis 

Astigmatism 

Atheroma 

Atrophy 

XX^tld •*• ••• ••• 



The faculty possessed by the eye to adapt itself to the distinct 

vision of near and distant objects, 
have violent symptoms, often attended with danger, terminating 

within a few days. 
Of adults. 
Egyptian. 
A state in which the skin, hair and the iris are destitute of 

their normal colour. 
A disease in which albumen (a substance similar to the white 

of an egg) is carried away with the urine. 
Total loss of vision, caused by paralysis of the optic nerve. 
Partial loss of vision. 
Deficiency of blood. 

A disease accompanied by the presence of a kind of worm. 
Without one or both eyes. 
Indigenous. 
The fluid in the eye between the cornea and crystalline lens 

(see below diagram of the eye, A.) 
Inflammation of a joint— gout, rheumatism. 
A condition of the eyes, in which there is a want of synunetry 

in their refractive surfaces. 
A morbid deposit causing little elevations in the arteries. 
Wasting or emaciation of a part. 
The straight line, real or imaginary, passing through a body 

on which it revolves or may revolve. 



Blennorrhcea ... A discharge of mucus or matter from a mucous membrane. 
Blepharitis Inflammation of the eyelids. 



Cadaver 
Caries 
Cataract 
Catarrh 



• • • • • • 



• • • • • • 



• t • m • • 



Dead body. 
... Disease of bones, analogous to ulceration of the soft parts. 
... Opacity of the crystalline lens, or its capsule. 

Afiection of a mucous membrane, causing increased discharge 
of mucus. 

Cerebro-spinal-meningitis. Inflammation of the membranes of the brain and 

spinal cord. 

Chemosis Inflammation of the conjunctiva of the eye attended by great 

redness and swelling. 



GLOSSARY OF TECHNICAL TERMS. 



239 



Choroid 



> • • • • • 



Choroiditis 

Ciliary Body 

Congenital 

Conjunctiva 

Conjunctivitis ... 
Conjunctival ... 
Consanguinity ... 
Cornea ... 



I • • • • 



Crystalline lens 



Cysticercus... 



A coloured vascular membrane lying behind the retina (see 

diag. Ch.) 
Inflammation of the choroid membrane of the eye. 
A part of the eye behind the circumference of the iris (see diag. 

Ci.) 
From birth. 
The mucous membrane covering the front of the eye-ball and 

inner surface of the eyelids (see diag. Cn.) 
Inflammation of the conjunctiva. 
Belonging to the conjunctiva. 
Relationship by blood. 
A transparent structure resembling a watch glass, forming the 

anterior fifth of the eye-ball (see diag. Cr.) 
or lens. The transparent refractive body Ijring behind the 

iris which focuses the rays of light on to the retina (see diag. 

L.) 
The germ of the tape worm. 



Diabetes 



• • • • • • 



• • • t • • 



Dacryo-cysto-blennorrhcea. a disease attended with discharge affecting the 

lacrimal sac. 
A disease in which a quantity of sugar is discharged by the 

urine. 
A disease in which the mucous membrane of various parts, 

chiefly the throat, air passages and conjunctiva becomes 

covered with a leather-like membrane. 
A diseased state of the general organism, 
A disease of the bowels attended with pain and a discharge of 

mucus and blood. 



Diphtheria 



Dyscrasia 
Dysentery 



• • • • • • 



ECTROPIUM ... 



Eczema ... 



• • • • • • 



Embolism 

Emmetropic... 

Encephalitis 

Endemic 

Entozoa 

Epidemic 

Epithelium ... 

Erysipelas ... 

Exanthemata 

Eye-clinics ... 



• • • • • • 



A disease in which the eyelid folds on itself, so that the con- 
junctival surface becomes external. 

A smarting eruption of small pustules without fever and not 
contagious. 

A clot of blood stopping up some blood vessel. 

The normal or perfect state of refraction of the eye. 

Inflammation of the brain. 

Any disease peculiar to a class of persons or to a country. 

Parasitical animals. 

Any disease which attacks many persons at the same time. 

A layer of minute cells covering surfaces of the body. 

A spreading inflammation of the skin. 

Cutaneous diseases. 

Hospitals in which eye diseases are treated. 



Febris recurrens. Relapsing fever, resembling typhus. 



240 



GLOSSARY OF TECHNICAL TERMS. 



Fluor albus ... A whitish mucous secretion from the vagina of women. 

FcETAL Belonging to the fcEtus. 

Foetus The unborn or immature child, from the fifth month of preg- 
nancy till birth. 

Follicle A little bag or simple gland. 

Fovea centralis A depression in the retina where that organ is most sensitive to 

the picture focused on it (see diag. F.) 



Glaucoma Dimness or defect of vision accompanied by opacity of the 

vitreous humour and hardness of the eyeball. 

Gonorrhoea A disease of a mucous membrane, originating in the sexual 

organs. 
GONORRHOICA) ^ , . 

Gonorrhoeal} - Belonging to gonorrhoea. 



haemorrhage 
Hemeralopia 

HYPERiEMIA ... 

Hypermetropic 
Hypopion 



• • • • « • 



A flow of blood. 

A olefect of vision by which objects are only seen in broad 

daylight. 
Excess of bloo)d in a part. 
The long sight of old age. 
A disease of the eye, attended with the presence of pus in the 

front chamber of the eye behind the cornea. 



Hypopion-Keratitis. Inflammation and abscess of cornea. 



Incubation ... 

Interstitialis 
Iridectomy ... 



Hatching, applied to the time taken by a disease to be 

developed after infection. 
Aflecting the interstices of a membrane or tissue. 
An operation in which a portion of the iris is removed. 



Irido-choroiditis Inflammation of the iris and choroid. 



Iridocyclitis 
Iris... 



• « # • • • 



Inflammation of the iris and ciliary body. 

The variously coloured membrane, pierced by a round hole 
(the pupil) which serves as a diaphragm to cut off super- 
fluous rays of light from the retina (see diag. I.) 



Keratitis Inflammation of the cornea. 

Keratomalacia ... Disease, accompanied by softening of the cornea. 



Lamellar 

Lazar-houses 

Leprosy... 



• • « • • 



• • • • • 4 



Leucorrhoea 
Leucoma 



• • ■ » • • 



In layers. 

Hospitals for quarantine. 

Disease in which the skin becomes excessively thickened and 

nodulated ; called also elephantiasis. 
Mucous discharge from female genitals. 
A milky opacity of the cornea, left by the scar of an ulcer or 

wound. 



GLOSSARY OF TECHNICAL TERMS. 



241 



Leukaemia A disease attended by increase of the white corpuscles in the 

blood. 

Liquor amnii ... The fluid enclosed in the membranes of the pregnant womb. 

Malacia of the Cornea. Softening of the cornea, same as keratomalacia. 

Marasmus Wasting of the flesh, emaciation. 

Meningitis Inflammation of the membranes of the brain or spinal cord. 

Menopause The period of the cessation of the menstrual discharge. 

Metastasis Transference of a disease from one place to another. 

Micrococcus ... A small spherical organism. 

Micro-organism ... A small living animal or vegetable. 

MiCROPHTHALMUS An abnormally .small eye. 

Myopia Short-sightedness. 

Myopic Short-sighted. 



Neonatorum 
Neuritis 
Nicotine 
Nodes 



• • • • • • 



Nystagmus ... 



Of new-born infants. 
Inflammation of a nerve. 
A poisonous alkaloid contained in tobacco. 
Hard circumscribed tumours on a bone, arising from a swell- 
ing of the bone or periosteum. 
A constant involuntary motion or oscillation of the eyeballs. 



Opacities ... 

Ophthalmia 
Optic Nerve 

Ora Serrata 



Dimnesses of the transparent parts of the eye obstructing the 

light. 
Inflammation of the eye. 
The large nerve that enters the eyeball at its back and spreads 

over the interior as the retina (see diag. O.) 
The finely indented border of the ciliary processes of the 

choroid where the retina ends (see diag. OS.) 



Parenchymatosa 

Phlyctena 

Phlyctenular .. 
Photometer 
Photophobia 
Physicatsexamen 

Pigmentosa 

Primipara 

Proglottides .. 
Prophylaxis 

Puerperal 

Purulent 
Pus 

16 



• • • • • • 



Of a fleshy character or appearance. 

A small vesicle on the conjunctiva of sclerotic or cornea. 

Belonging to phlyctena. 

A light-measurer. 

Intolerance of light. 

The examination for the office of Physicus. 

With increased deposit of pigment or colouring matter. 

A woman in her first accouchement. 

Segments of intestinal worms. 

Preventive treatment. 

Belonging to, or consequent on child-bearing. 

Consisting of pus. 

Matter. 



242 



GLOSSARY OF TECHNICAL TERMS. 



Pyaemia 



♦•« 



... A disease accompanied by the presence of matter or pus in the 
blood. 



Rachitis 



Refraction 



Retina , 



Retinitis 



I • • • • 4 



A disease peculiar to children, characterised by softening and 

distortion of the bones. 
The angular deviation of an oblique ray of light -when it 

passes from one transparent medium to another of different 

density. 
The expansion of the optic nerve over the inside of the eye, 

(see diag. R.) 
Inflammation of the retina. 



Saturnine Poisoning. Poisoning by lead. 

Sclera or Sclerotic. The thick opaque case of the eyeball (see diag. S). 



Scotoma... 
Scrofula 

Scurvy ... 



Sequelae 
Serpens... 
Snellen 
Sporadic 



Staphyloma... 



Syphilis... 



t • • • • • 



• • • • • • 



• • • • • • 



A black or dark spot seen by the patient. 

A dyscrasia or general disease originating in a morbid con- 
dition of the l3mnphatic glands or transmitted hereditarily. 

A disease characterized by great debility, a spongy state of 
the gums and a tendency of the blood to escape from its 
vessels. 

After effects — secondary diseases. 

Of a serpentine form. 

The name for a series of test types, introduced by Dr. Snellen. 

Applied to infectious diseases which seize only a few persons 
at a time. 

A bulging of a part of the eyeball, often attended by the pro- 
trusion externally of portions of the interior of the eye. 

A disease caused by venereal poison being received into the 
system. 



TiENiA Solium 
Thrombosis ... 
Trachoma ... 

Trachomatous 
Traumatic ... 
Trichiasis ... 

Tuberculosis 



The tape worm. 

A clot of blood obstructing a blood vessel.^ 
A disease of the eye, attended by a granular condition of the 

conjunctiva and a discharge. 
Belonging to trachoma. 
Belonging to a wound. 
A disease in which the eyelashes are turned in towards the 

eyeball. 
A disease attended by the formation of tubercles. 



Ulcus Ulcer ... A solution of continuity in any soft part of the body, with a 

discharge of pus. 
Uvea, or Uveal Tract. The dark pigment at the back of the iris (see diag. U). 



DIAGRAM OF THE EYK 



Variolous. Relating to small-pox. 

Visceral Relating to the intestines or ioternal oigans. 

Vitreous Hi;moi;r A clear fluid enclosed in a transparent membrane filling the 
eyeball from tbe crystalline lens to the retina (see diag. V.) 



DIAGRAM SHOWING THE PRINCIPAL PARTS OF THE EYE. 




INDEX. 



Abscess of the cornea, 84 — 88, 176, 177. 

Adler's model writing books, 67. 

Alcoholic poisoning, 99 — loi. 

Amblyopia, see Alcohol and Tobacco. 

Anchylostoma, 93. 

Arsenical poisoning, 230, 

Artificial stone slates, 67. 

Athletics, 73. 

Atrophy of optic nerve, 91, 94. 

Barracks, 148, 160 — 164. 
Baths, Sanatoria, at, 21. 
Belladonna poisoning, 230. 
Blennorrhoea acuta adultorum, 104, 106, 

107, 109, 142 — 146. 
Blennorrhoea chronica, see Trachoma. 
„ neonatorum, 104 — 109, ill 

— 142. 
Blennorrhoic conjunctivitis, 104 — 170. 
Blindness, definition of, i, 2. 
,, preventible, 229. 
Body, position of the, in writing, 50, 55 

—59. 
Book-print, see Type. 

Bums of eye, 179. 

Cataract, 95. 

Causes of blindness, statistics of, 5, 6. 
Childhood, eye diseases of, 17 — 23. 
Children, factory work of, 191, 192. 

injuries in, 179 — 182, 186. 

separation of newborn, 25, 26. 
Cholera, 83. 



ij 



>9 



Choroiditis metastatica, 90. 

Climate, influence of, on eye diseases, 

201, 202. 
Clinics, ophthalmological, 211 — 217. 
Colza oil for lighting, 196 — 200. 
Compositors, myopia of, 174. 
Conjunctivitis foUicularis, 146, 150. 
Consanguineous marriages, 12 — 17. 
Cornea, abscess of, see Abscess. 
Cornea, affections of, in acute febrile 

diseases, 83 — 88. 
Cornea, opacities of, 18. 
Crede*s prophylactic method, 125 — 131, 
Culture of the people, 190 — 192. 
Curtains in school-rooms, 48. 
Cysticercus, 93. 



Definition of blindness, 112. 

,, weak sight, i, 4. 
Diphtheric conjunctivitis, 170^173. 
Dispensaries, eye, 217 — 222. 
Drawing, 63, 64, 234. 
Dysentery, 91. 



Electric lighting, 49, 64, 193— 200. 
Enucleation, 187, 188. 
Erysipelas, 92. 

Explosives, injuries from, 181, 182. 
Eye, diagram of, 243. 

,, dispensaries, 217 — 222. 

„ hospitals, 210 — 216. 



INDEX. 



245 



Febris recurrens, 89. 

Follicular catarrh, 150. 

Foundling hospitals, blennorrhoea in, 

113, 116, 135, 145, 146. 
Fusel alcohol, 100, loi. 

Gas illumination, 49, 195 — 200. 
Glaucoma, 81, 95, 203. 
Glossary of technical terms, 238. 
Goldsmiths, myopia in, 174, 175. 
Gonococcus, 108. 
Gonorrhoea, 142, 146. 
Granulations, see Trachoma. 
Gynmastics, 66, 70, 236. 

Handwriting, physiology of, 55. 

Heat, production of, in artificial lighting, 

196. 
Holiday colonies, 19, 20. 
Holidays, 73. 

Home-work .of scholars, 72, 73. 
Hygiene, instruction in, 204, 20$. 

Inherited eye diseases, 8. 
Injuries of the eye, 177 — 187. 
Instruction in ophthalmology, 205 — 216. 
Iridochoroiditis, 89, 90, 95. 

Jews, glaucoma in, 203. 

trachoma in, 154, 237. 



9J 



Kallmann's upright holder, 54. 
Keratitis xerotica (neuro-paralytica), 84. 
Keratomalacia, 22, 88. 

Lead poisoning, 102, 103. 

Leprosy, 12. 

Lessons, see School-lessons. 

Letters, see T)rpe. 

Lighting, artificial, 49, 192 — 201. 

,, electric, 49, 64, 193 — 200. 

,, of schoolrooms, 37 — 50. 



Lighting of workrooms, 175. 
Local Government Board, 225, 226. 
Lochial secretion, 113, 134. 
Lying-in hospitals, blennorrhoea in, 115 
—118. 

Malacia of cornea, 22, 88. 

Manual work, 63, 64. 

Maritime stations, 20, 21. 

Marriages, consanguineous, 12 — 17. 

Measles, 88, 91. 

Medical supervision of schools, 75 — 82, 

167 — 169, 220 — 224. 
Medical supervision of soldiers, 144, 159 

— 164. 
Meningitis, 83, 89, 91. 
Metal-workers, injuries of, 178 — 180, 184 

—186. 
Metastatic choroiditis, 90. 
Middle schools, 68—73. 

,, medical supervision of,. 

80, 81. 
Midwives, 132 — 134. 
Miners, injuries of, 181. 
Musee pedagogique (scolaire), 80. 
Myopia, congenital, 25. 

„ dependent on occupation, 26,. 

27, 174, 175- 
Myopia in the female sex, 33. 
„ in schools, 28 — 32. 
,, influence of race on, 34, 35. 
„ prophylaxis of, 36 — 82. 

Navy, trachoma in the, 152. 

Negroes, trachoma in, 156, 203. 

Neuritis, 8, 92, 94. 

Neuro-retinitis, 93, 94. 

New-born infants, blennorrhoea of, 104 

— 109, III — 142. 
New-bom infants, refraction of, 25. 
Nicotine, see Tobacco. 



246 



INDEX. 



Normal lamp, 197. 
Nurses, 135, 143, 144. 

Occupation, influence of, on eye diseases, 

174—188. 
Occupation, influence of, on myopia, 26, 

27, 174, 175- 
Oculists, 218—222. 

Overwork in middle schools, 68 — 71. 

Paper for school-books, 63, 236. 
Petroleum, 195 — 200. 
Photometry in schools, 38, 39. 
Poisoning, chronic, 96. 
Pregnancy, 94. 
Preventible blindness, 229. 
Primary schools, 65 — 68. 

,, medical supervision of, 

80. 
Prize -jury, report of, ix. 
Protective spectacles for work-people, 

184, 187. 
Puerperal fever, 90. 
Pyoemia, 83, 90. 

Race, influence of, on eye diseases, 202, 

203. 
Race, influence of, on myopia, 34, 35. 
,, on trachoma, 157. 

Reading, 60—63, 235. 
Reapers, injuries to, 176. 
Retinitis pigmentosa, 13, 14. 

Sanatoria in watering places, 2i. 
Sanitary authorities, 222 — 226. 
Scarlatina, 88, 91. 
School buildings, 40 — 44. 

„ doctors, 75—82, 168, 237. 

„ lighting of, 37—50. 

„ hours, arrangement of, 66, 71. 



School hours, number of, 65, 70. 

,, myopia in, 28 — 32, 

„ scats, 52—54, 233. 

,, trachoma in, 149, 153. 

,, windows, 43 — 48. 
Scrofula, 9, 17 — 22. 

Seats and desks, construction of, 51 — 54. 
Short-sightedness, see Myopia. 
Skylight in schools, 44. 
Slates, 67, 68. 
Small-pox, 84 — 88. 
Social conditions, influence of, on eye 

diseases, 189 — 201. 
Society for Prevention of Blindness, 

secretary's report, v. 
Soldiers, trachoma in, 147 — 152, 157 — 

164. 
Spirits, see Alcohol. 
Statistics of causes of blindness, 5, 6. 
Stenography, 60. 
Stone-masons, corneal abscess of, 178 — 

180, 184. 
Stuhlmann's point system, 64. 
Sulphur baths, 103. — 
Sundajrs, 73. 
Sympathetic ophthalmia, 180, 183, 186, 

187, 188. 
Syphilis, eye diseases in, 94, 95. 
,, hereditary, 10—12. 

Tabes, 94. 

Tobacco-poisoning, 96—99. 

Toys, dangerous, 179, 182, 186. 

Trachoma, 105—108, 237, 146 — 170, 237. 

Tuberculosis, 9, 10. 

Type, 61, 63. 

Typhus, 83, 88, 89, 91. 

Upper schools, 74. 
Upright-holder, Kallmann's, 54. 



INDEX. 



247 



Vaccination, 86, 87. 
Vaginal catarrh, 112. 

„ secretion, iii — 112, 114, 123. 
Variola, see small-pox. 

War, injuries of eyes in, 182, 183. 
Watchmakers, myopia in, 174, 175. 
Weak-sight, definition of, i — 4. 



Windows, see School-windows. 
Women, myopia in, 33, 
Work, home, of scholars, 72, 73. 
Writer's cramp, 58. 
Writing, methods of, 56, 59. 
Writing, position of body in, 52, 55 — 59^ 
232—234. 



John Bale & Sons, Steam Printers, 87-89, Great Titchfield Street, W. 



BAILLIERE, TINDALL & COX, 20, King William Street, Strand. 



WORKS BY Dr. ROTH. 



Prize Medals bave bern awarded at the Inters a'ional Exhibitioiis of Londan in 1862, 
and Paris, 1867, for Sr. Both*s Works on Physical Education, Models, &e. Gold Medal, 

Health Exhibition, 188i. 



On the Movement Cure. 

1. A Short Sketch of Rational Medical Gymnastics, or, the 

MOVEMENT CURE. With Thirty-eight Engravings, is. 

2. The prevention and CURE of Many Chronic DISEASES 

BY MOVEMENTS. With Ninety Engravings. los. 

3. The handbook of the MOVEMENT CURE. With One 

Hundred and Fifty-five Original Engravings. los. 

4. Brand's Treatment of Female Diseases by the MOVEMENT 

CURE. Translated by Dr. Roth. 5s. 

5. The Treatment of Writer's CRAMR is. 

On Paralysis, 

6. Contribution to the Hygienic Treatment of PARALYSIS, 

and of PARALYTIC DEFORMITIES. With Thirty-eight 
Engravings. Illustrated by Numerous Cases. 3s. 6d. 

7. ON PARALYSIS IN INFANCY, CHILDHOOD, and YOUTH 

AND ON THE PREVENTION AND TREATMENT OF PARALYTIC 

Deformities. With Forty-five Engravings. 3s. 6d. 

8. Contributions to the Treatment of Facial Paralysis. 66. 

On Spinal Curvatures, 

9. The Prevention and Treatment of SPINAL DEFORMITIES, 

especially of Lateral Curvature, with notes on the causes, 
the artificial production, and injurious modes of treatment of 
these complaints. With Fifty-three Engravings. 5s. 

10. Notes on Sayer's Treatment of Angular Curvature. 6d. 



WORKS BY DR. ROTH. 



11. On lateral CURVATURE. Notes on the Examination, 

Prognosis and Treatment, is. 

12. On the Influence and Use of the Will in the Treatment 

OF Many Spinal Deformities. 6d. 



Balneological Pamphlets. 

13. Medical and other Notes, collected on a Holiday Tour to 

Arcachon, Biarritz, Pau, and the principal Watering Places 
in the Pyrenees, is. 6d. 

14. Divonne-les-Bains in Spring and Autumn. Notes on its 

Sanatorium and Hydropathic Establishment. 6d. 

15. The Hot Springs of Bourbonne-les-Bains. (The French 

Kreuznach.) 6d. 

16. The Russian Bath, published with a view to recommend its 

introduction into England for Hygienic as well as curative 
purposes, with some suggestions regarding Public Health 
Second Edition, is. 



Miscellaneous Papers, 

17. On Hahnemann's Merits, Errors, and Critics, is. 

18. On Fear and Fright and the Diseases they Cause and 

Cure. is. 

19. Bone Setters and Rubbers. 6d. 

20. On Compulsory Medical Inspection of all Schools. Paper 

read at the SociAe M^dicale du Bureau de Bienfaisance, 
13 Octobre, 1880. 6d. 

21. On the Prevention of Blindness. 6d. 

22. The Fever-dens in the North- Western and West Central 

Districts in London. 6d. 

^7 



WORKS BY DR. ROTH. 



On Scientific Physical Education and Hygiene, 

23. On the Importance of Rational Gymnastics as a Branch 

OF National Education: a Letter to Lord Granville, is. 

24. On Scientific Physical Training and Rational Gymnastics : 

a Lecture delivered at the request of the Committee, at the 
Royal United Service Institution, is. 

25. A Plea for the Compulsory Teaching of Physical Educa- 

tion. IS. 

26. On the Ladies' Sanitary Association (of London) and their 

Work. Paper read at the International Congress of Hygiene 
in Turin in 1880. 

27. On the Neglect of Physical Education and Hygiene as a 

Cause of the Deterioration of the Physique of the Population. 
IS. 6d. and 2S. 

28. On Scientific Physical Education and its Practical 

iNTRODUcnoN INTO SCHOOLS. An Address delivered at the 
request of the Committee before the Conference of Teachers, 
January, 1880. 6d. 

29. L'Education Physique Scientifique et l^Hygi^ne Scolaire. 

Lettre k M. le Ministre de ITnstruction Publique en France, 
1880. 6d. 

30. LTntroduction des Elemens de l'Hygiene et de l'Education 

Physique Scientifique dans toutes les Ecoles Primaires 
et Secondaires. Paper read at the International Congress 
of Hygiene in Turin, in 1880. 6d. 

31. Gymnastic Exercises without Apparatus according to Ling's 

System. With Forty-two Illustrations. For the develop- 
ment and Strengthening of the Human Body in Childhood 
and in Youth. Sixth Edition, is. 

32. A Table of a few Gymnastic Exercises without Apparatus. 

With Thirty-three Wood Engravings. 6d. 



WORKS BY DR. ROTH. 



33. Table, showing a few Injurious Positions to be avoided during 

time of Education and growth, and some deformities of the 
Spine, produced partly by bad positions, and partiy by tight 
lacing. With Forty-six Engravings. Eleventh Thousand. 6d. 

34. Two Tables of Gymnastic Exercises without Apparatus ; with 

Explanations. Mounted on Cloth, with Rollers, Varnished. 
Per set 3s. 6d. 

35. The Gymnastic Exercises of Ling, arranged by Rothstein; 

translated by Dr. Roth. Second Edition. 2s. 6d. 

36. Gymnastic Exercises on Apparatus, according to the Rational 

System of Ling, with 80 Illustrations, is. 

37. Gymnastic Games. These consist of a series of Thirty-six Cards. 

Each Card presents an accurate representation of some 
position in which the body is to be placed, as a Gymnastic 
Exercise. The Cards are accompanied by instructions ex- 
plaining the methods of playing various amusing Games, and 
at the same time they are most efficient in promoting a healthy 
development of the muscles, and form a system of physical 
training. In a cloth case is. 6d. 

38. Gymnastic Models, copied from Dr.' Roth's Collection in the 

South Kensington Museum. These Models are executed in 
Papier Mach^, each twelve inches in height. The price of 
the set of Twenty-four, mounted on hard wood, is ;^3. 
A selected set of Twelve Models on a slightly smaller scale 
may be had, price 30s. 

39. On the Causes of the Great Mortality of Children and 

THE Means of Diminishing them. A paper read before the 
Scientific Congress at Rouen, and the International Medical 
Congress in Florence, in 1869. Also a French, Italian, and 
Hungarian translation. 6d. 



Price 3s. 6d. 



THE HUMAN EYE; 

Its Optical Construction popularly explained, 



BY 



R. E. DUDGEON, M.D. 



LONDON : 
HARDWICKE AND BOGUE. 



1878. 



Price 2s. 6d. 



THE SPHYGMOGRAPH ; 

Its History and Use as an aid to Diagnosis in 

ordinary practice, 

BY 

R. E. DUDGEON, M.D. 



LONDON : 
BAILLIERE,' TINDALL & COX. 

1882. 



ALPHABETICAL INDEX OF AUTHORS. 



ABERCROMBIE (J.) On Tetany in Young Cliildien 13 

ADAMS (W.) Deformities (in Gant's Suc^ery) 27 

ALLEN (Alfred) Microscopical Science 23 

ANNANDALEfTbos.) Abstracts of Surgical Principles aS 

ATKINSON— Hints in the Obsletrical Precedure 24 

BAKER (Benson) How lo Feed an Infant 24 

BARNES (Robt.) Diseases ofWomen (in Gant's Surgery) 24 

BARRAUD (H. R-J Picture of the International Medical Congress so 

BEACOCK(J.) Prize Essay on Breeding Cattle, etc 34 

BELL (J). Manual of Surgical Operations 2S 

BERNARD (Claude) and HUETTE'S Teitt-bnok of Operative Surgery 28 

BLACK(C}.Atias of the Organs of Generation (Male) 8 

BLACKLEV (C. H.) Hiy Fever, its Causes and Treatment 18 

BLAKE f Carter) Translation of Fau's Anatomy for Artists 9 

BODDY(E. M.) History of Salt 27 

BOYD (Stanley) Movable Atlas of the Toot, its Bones and Muscles 8 

BRAMWELL(Byrom) Diseases of the Spinal Cord 27 

BROCHARD (J.) Practical Guide for the Young Mother 24 

BROWN (George) The Student's Case-book II 

Aids lo Anatomy _ 7, 32 

Aids to Surgery 33 

BROWNE (BalfourJ Mental Responsibility and Disease n 

BROWNE (Lennox) The Throat and its Diseases 30 

Forms for taking Throat and Aural Cases 12 

Movable Atlas ofthe Ear and Teeth 8 

BROWNE (W. J.) The Moon, its Influence on Weather aa 

BURNESS (A. G.) The Specific Action of Drugs 15 

CAMERON (Chas.) Microbes in Fermentation, Putrefaction, and Disease ... aa 

The Cholera Microbe and How to Meet It 14 

A Romance of War 31 

CARTER (R, Brudenell) Training of the Mind 23 

CANTLIE(Jas.) Atlas of the Hand g 

Text-book of Anatomical Plates , 7 

CASSELLS (J. Patterson) Translation of Pulitzer's Diseases of the Ear ij 

Deaf-mutism and the Education of the Deaf-mule 15 

CHARCOT (J. M.)BriEht's Disease ofthe Kidneys 20 

CHAUVEAU-FLEMING. Comparative Anatomy of the Domestic Animals 34 

CLARKE (E. H.) The Building of a Brain II 

COCKLE (John) Contributions to Cardiac Pathology 19 

— Insufiiciency ofthe Aortic Valves 18 

COHNHErM(Prof.) On the Contagiousness of Consumption 14 

COLE (A, C.) Studies in Microscopical Science 23 

COLES (Oakley) The Dental Student's Note Book 28 

CKOOM(J. Halliday) Minor GynEccological Operations 18 

CULLIMORE (D. H.) Consumption as a Contagious Disease 14 



k 



Baillifere, Tindall. and Cox's Books. 



DARLING (W.) Anatomography, or Graphic AEitomy 9 

The EasenliaU of Analomy 7 

DAWSON (W.E.) Guide to the Examinations or the ApolhecarieB' Society iG 

DENNIS (Hy. J.) Second-Grade Perspective Drawing 9 

~- — Third-Grade Perspective Drawing lo 

DOLAN(T. M.) Whooping Cough, its Pathol(«y and Treatment 31 

DOWSE JT. Stretch) Ataxia 10 

Apoplexy 9 

Syphilis of the Brain and Spinal Cord 11 

Neuralgia.; its Nature and Treatment II 

Skin Diseases from Nervous Affections ay 

The Brain and the Nerves 11 

Movable Allasoflhe Brain and SkuU 8 

DRAGENDORFF (Prot G.) Plant Analysis ay 

DRVSDALE{C. R.) Nature and Treatment of Syphilis aS 

DRYSDALE (John) The ProLoplasmic Theory of Life 39 

Life and the Equivalence of Force 39 

Germ Theories of Infectious Diseases 38 

DUDGEON (R.E.) The Sphygmograph ay 

DUFFEY (G. F.) Text-book of Materia Mcdica and Pharmacy ai 

EGAN (and Maybury) Aids to the Classics 39 

EVANS (C. W. De Lacj;) How lo Prolong Life? 19 

Consumption: its Causes, Treatment, etc 14 

FAU (J.) Artistic Analomy of the Human Body g 

Anatomy of the External Forms of Man 9 

FEARNLEY (W.) Text-book for the Enaminatjon of Horses .. ... 34 

Simple Ailments of Horses, There Nature and Treatment 34 

Lesson-s in Horse Judging 34 

FITZGERALD (H, P.) Dictionary of British Plants and Flowers 11 

FLAXMAN(J.) El ementaiy Anatomical Studies for Artists 9 

FLEMING (G.) Text-book of Veterinary Obstetrics 34 

Text-book of Veterinary Surgery 35 

Veterinary Sanitary Science and Police 35 

Practical Horse-Shoeing 35 

Animal Plagues, their History, Nature and Treatment 35 

znd Series, 1800 to 1844 35 

— ■■ - — Contagious Diseases of Animals 35 

Tuberculosis 14 

Human and Animal Variola; 35 

Heredity and Contagion in the Propagation of TuberculoEis 35 

FOTHERGILL (J. Milner) Chronic Bronchitis I[ 

Aids lo Diagnosis (Semeioli^ical) '5>31 

Aids lo Rational Therapeutics 33 

The Physiological Factor in Diagnosis le 

The Physiologist in the Household aS 

Diseases of Sedentary and Advanced Ijfc 24 • 

GANT(F. J.} Text-book of the Science and Practice of Sureery 37 

Diseases of the Bladder, Prostate Gland, and Urethra 30 

— . Guide to the Examinations at the College of Surgeons 16 

GIRAUD-TEULON-AnomaliesofVisioo 16 

GLOVER (J. G.J Medical Reform aa 

GOODELL (Wm.) Lessons in Gymecology iS 

GORDON (Chas. A.) Our Trip to Burmah it 

. Life on the GnM Coast 7 



Baillifere, Tindall, and Cox's Books. 



GORDON (Chas. A.) A Manual of Sanilation 

ReporiB of the Mcdk-al Officers of Chinese Service 

GORE (Albert A.) Our Services Under (he Crown 

— Medical History of African Campa^jns 

GRAY— The Pocket Gray, or Anatomist's Vade-Mecum 

GREENWOOD (J.) Laws Affecting Medical Men 

GREENWOOD (Major) Aids to Zoology 

GRESSWELL (J. U. and A. G.} Manual of Equine Medicine 

GREVILLE (H. L.) Chemistry 

GRIFFITHS (W. H.) Test -book of Materia Medica and Pharmacy ... 

Notes on the Pharmacopoeial Prepaiationa 

Fosological Tables 

A System of Botanical Analysis 

GUBB (Alfreds.) Aids to Gynecology 

GUBLER (Professor) The Principles and Methods of Therapeutics 

GUILLEMARD (F. H. H.) Endemic Hranaturia 

HALTON (R. J.) Short Lectures on Sanitaiy Subjects 

HARRIS (Vincent) Manual for the Physiological Laboratory 

HARTMANN (Prof.) On Deaf-mutism, Translation by Dr. Casseils 

HAYNES (Stanley) Healthy Homes 

HEATLEY (G. S.) Practical Velcrmory Remedies 

HEMMING (W. D.jAidstoExamiuations 

Aids to Forensic Medicine 

Olorrhoea 

HENRY (Alex.) Posolt^cal and Therapeutic Tables 

HILL (J. W.) Man^ement and Diseases of the Dog 

Principles and Practice of Bovine Medicine 

HIME(T. W.) Cholera; How to Prevent and Resist It..., 

The Practical Guide to the Public Health Acts 

HOGG (Jabei) The Cure of Cataract 

The Impairment of Vision from Shock 

— — Parasitic Or Germ Theory of Disease 

HOPGOOD (T. F.) Notes on Surgical Treatment 

HOWAT (G. R.) How to Prevent and Treat ConsamptiDD 

HOWE (J. W. ) The Breath, and Diseases which give it a Ftetid Odour 

HUSBAND (H. Aubrey) Handbook of Forensic Medicine 

Aids to the Analysis of Food and Drugs 

Handbook of the Practice of Medicme , 

Student's Pocket Prescriber , 

A Digest of the Sanitary Acts of England , 

INGE (J.) Latin Grammar of Pharmacy 

JACOB (A. H.) The General Medical Council 

JAMES (M, P.) Laiyngoscopy and Rhinoscopy in Throat Diseases 

Therapeutics of the Respiratory Passages 

Vichv and its Therapeutical Resources 

JENNINGS (C. E.) On Tiaui>fuslon of the Blood and Saline Fluids 

JONES (H. Macnaughlon) The Diseases of Women 

JUKES-BROWNE (A. J.) Pakeontology (in Pennmg's Field Geology) . 

KEETLEY (C.R. B.) Guide to the Medical Profession 

Annals of Surgery 

KENNEDY (Hy.) An Essay on Fatty Heart 

KINGZETT(C-T,) Natures Hj^iene 



Bailli^re, Tindall, and Cox's Books. 



LAFFAN (T.) The Medical ProTes^on of the tToitcd Kii^Dm (Second Cu- 

michael Priie Esaay) 

AMBERT ( J.) Tae Gcr m Theory of Duease 

LEE [R, J.) Lectnns on Disease! of Children _ ^. 

LETHEBy(Ky.) A Treatise on Food „ „. 

The Sewage Qnealion „ „ 

LEASK(J. G.) Queitions at Medical Sdatee Eawnnwrtiom 

LIAUTARD {A.) Animal Castration _ „ 

LITTLE (Jus.) Clinical Note-Book 

LOWNE (B. T.) Art Students' PhyaioLofir 

Aids to PhTsiology 

LUNN (C) The Philosophy of Voice 

Artistic Voice in Speech and Song 

MACBRIDE (J. A.) Anatomical Outlines of the Horse 

MACDONALD (Angus) Materia Medica and Therapeutics 

MACKENZIE (M.) Diseases of the Throat (in Ganl's Surety) 

McLACHLAN (John) Handbook of Surgical Anatomy 

MAHOMED (F. A.)TheSphygmograph(inGanl'a Surgery) 

MA POTHER (E. D.) A Manual of Physiology 

MASSE (J. N.) Text-book of Anatomical Plates 

MAYBURV (and Egao) Aids to the Classics 

MAYER (T. W.) Anatomical Ouilinea of the Horse 

MEARS (W. P.) Schematic Anatomy 

MELDON (Austin) A Treatise on Gout 

MEVRICK (J, J.) Stable Management and the PievenCion of Diseases among 

Horses in India _ 

MILLARD (H. B.) Bright's Disease of the Kidneys 

MILNE (Alex.) The Principles and Practice of Midwifery 

MOORE (E. H.) Clinical Chart for Hospital and Private Practice 

MORGAN (John) The Dangers of Chloroform and the Safety and Efficiency 

of Ether in Surgical Operations _ 

MUCKLEY (W.J.)Student'sManiialof Artistic Anatomy 

A Handbook for Painters and Art Students on Ihc Use of Coloma 

MUTER (J.) Key to Organic Materia Medica 

Introduction to Analytical Chemistry 

■ Introduction to Pharmaceutical Chemistry 

Inlroduclion to Pharmaceutical and Medical Chemistry 

MURRAY (R. Milne) Chemical Notes and Equatious 

NALL (S.) Aids to Obstetrics 

NAPHEYS (G. H.) Modem Medical Therapeutics 

Modem Surgical Therapeutics 

Handbook of Popular Medicine 

NORTON (A. T.)Tex|.book of Operative Surgery 

Osteology for Students 

Affections of the Throat and Larynx 

Clinical Lectures on Hoarseness 

Movable Atlas of the Skeleton , 

ORMSBV {L. II.) Deformities of the Human Body 

— -^_ Phimosis and Paraphimosis 

OWEN (Lloyd) Translation of Giraud-Teuloii's Anomalies of Vision. 

PALFREY (J.) Atlas of the Female OrEins of Generation 

PALMER (J. F.) How to Bring up Children by Hand 

PARRISH (Ed.) A Treatise on Pharmacy 



Baillifere, Tindall, and Cox's Books. 5 

PENNING (W. H.)Text.book of Field Geology "i'y 

Engineerine Geolc^ ij 

■ — - Notes on Nuisances, Drains, and Dwellings 19 

PETTENKOFER (Von) Cholera : How lo Prevent and Resist it 13 

POLITZER (Prof.) The Ear and its Diseases 15 

POMEROV(0. D.) On Diseases of the Ear r; 

POWER (Hy.) Movable Atlas of the Eye, and the Mechanism of Vision 18 

Diseases of the Eye (in Gant's Surgery) 87 

POWER (D'Arcy) Handbook for the Physiolorical Laboratory 26 

PRATT (W.) A Physician's Sermon to Young Men 23 

PROCTOR (Richd.) The Stars and the Earth 10 

PSYCHOLOGIGAL ASSOCIATION'S Handbook for Attendants on the 

PURVES (L.JAuiai Diseases [in Gant's Surgery) '...', 27 

REMSEN (Iia) Principles of Theoretical Chemistry 13 

REYNOLDS (R. S. ) The Breeding and Management of Draught Horses 36 

RICHARDS (J. M.) A Chronology of Medicine aa 

RICHARDSON(a W.) The Healthy Manufacture of Bread 7 

RICHARDSON (Thos.) Chemistiy in its Application to the Arts and Manu- 

RlVINGTON'iwVrilieM'i^Vt^i Profusion (F^ 31 

Medical Education and Oi^aniiation 21 

ROBERTSON (William) A Handbook of the Practice of Equine Medicine,.. 36 

ROCHET (Oias.lThe Prototype of Man, for Artists 10 

ROTH (M.) Worts on Deformities, Gymnastic Eiercisos, etc 18 

ROUTH(C. H. F-tOveiwork and Premature Mental Decay 25 

-On Fibrous Tumours of the Womb 24 

On Checks to Population 26 

SCHELL (Hy. C.) Manual of Ophthalmic Practice 16 

SCHOFIELD (A. T.) Pathology Examination Cards 25 

SCORESBY-JACKSON (R. E.) Nnte-Book of Materia Medica 20 

SE1LER(C.) A Compendium of Microscopical Technology 22 

SEMPLE(R. H.) Diphtheria, Its Causes and Treatment 15 

Movable Alias of the Human Body (Neck and Trunk) S 

SEMPLE{C. E. A) Aids to Botany 10,32 

Aids to Chemistry , 33 

— ■ Aids to Materia Medica 21 

Aids to Medicine 33 

Aids to Pharmacy 33 

Diseases of Children 13 

— The Voice Mnsically and Medically Considered 31 

SEWILL{Hy.) Movable Atlas of the Teelh "8 

SIMON (W.) A Manual of Chemistry for Beginners 12 

SPITZKA(E. C.) The Diagnosis and Treatment of Insanity zo 

SQUIRE (P, WOPosological Tables 26 

STARTIN (J.) Lectures on Ringworm 27 

STRANGEWAYS (Thos.) Text Book of Veterinary Anatomy 36 

STUDENTS' AIDS SERIES 32 

SWEETING (R. D. R.) The Sanitation of Public Institutions 19 

TAIT (Lawsan) Diseases of the Ovaries 25 

TELLOR(L.V.) The Diseases of Live Slock 36 

THIN (George) Introduction to Practical Histology 19 

THOMSON (W.)TransactioQsofthe Academy of Medicine in Ireland 30 



IL 



Bailliere. Tindall, and Cox s Books. 



PAGE 

THORO WGOOD ( J. C .) Consumption ; its Treatment by the Hypophosphites 14 

The Treatment of Bronchial Asthma 10 

Aids to Physical Diagnosis 32 

THUDICHUM (A. L.) The Physiological Chemistry of the Brain 11 

Aids to Ph3rsiological Chemistry 26 

Aids to Public Health 27 

TICHBORNE (Professor) The Mineral Waters of Europe 23 

TIMMS (G.) Consumption ; its Nature and Treatment 14 

Alcohol in some Clinical Aspects, a Remedy, a Poison 7 

TOMES (C. S.) Dental Sui^ery (in Gant*s Surgery) 28 

TYSON (J.) The Urine, a Guide to its Practical Examination 30 

VAUGHAN (J.) Strangeways* Veterinary Anatomy 36 

WALLER (B. R.) Interstitial Nephritis 23 

WALLEY (Thos.) The Four Bovine Scourges 36 

WEST (J. E.) Syllabus of Vertebrate Morphology 31 

WHARRY (Robt.) Guide to the Medical Profession 21 

WILLSON (A. Rivers) Chemical Notes for Pharmaceutical Students 13 

WI LSON (Sir Erasmus) Diseases of the Skin (in Gant*s Surgery) 27 

WILSON (J.) A Manual of Naval Hygiene 19 

WINSLOW(L. S. Forbes) Manual of Lunacy 20 

Chart of the Lunacy Acts 20 

Handbook for Attendants on the Insane 20 

Spiritualistic Madness 20 

Fasting and Feeding 16 

Aids to Psychologic^ Medicine 33 

WISE (A. T. Tucker) Wiesen. As a Winter Health Resort in Early Phthisis 7 

The Alpine Winter Cure 7 

WITKO WSKI (G.J.) Movable Atlases of the Human Body 8 



Baillifere, Tindall, and Cox's Books. 



ALPHABETICAL INDEX OF WORKS. 

MEDICINE, SURGERY, SCIENCE AND AKT, 



BAILLlfiRE, TINDALL, & COX. 

Africa- A Contribution to the Medical History of our West 
African Carapaigna. By Surgeon-Major Albert A GoRE, MD., 
Sanitary OfScer on the Staff. Price lOa. 6d. 

" A mo9t iDterefltlng record of a HgrieB of Htlrrfng DVButa in which tba Author took an 
mcti¥e part, oud of alftbotute precAiitlouA fur tha lualntenaucB Qfhadth."—Medv:otPrfie, 

A&ica- Life on the Gold Coast. Being a full and accurate Descrip- 
tion of the Inhabitants, their Modes and Habits of Life ; 
interspersed with amusiiig Anecdotes, Hints to Travellers and 
others in Western Africa. By Surgeon-General Gordox, M.D., 
C.B., Hon. Physician to the Queen. Price 2s. 6d. 

Alcohol, in some Cliniual Aspects : A Remedy, a Poison. By 
Godwin Tmms, M.D., M.R.C.P. Lond., Senior Physician to 
the North London Consumption Hospital. Price la. 

Alps. The Alpine Winter Cure, with Notes on Davos PJatz, 
Wiesen, SL Moritz, and the Maloja. By A. T. Tucker Wise, 
M.D., formerly Physician to the Margaret Street Infirmary for 
Consumption. Illustrated. Price Ss. 6d. 

Alps. Wiesen as an Alpine Health Resort in Early Phthisis, with 
Instructions on Clothing, Diet, and Exercise in the Swiss Alps 
during Winter. By the same Author. Price 3s. 6d. 

Anaesthetics. The Dangers of Chloroform and the Safety and 
Efficiency of Ether in Surgical Operations. By John Moeqan, 
M.D,, F.R.C,8. Second thousand, price 23. 

Anatomy. Aids to Anatomy. By George Brown, M.R.C.S., Gold 
Medalist, Charing Cross Hospital. Eighth thousand, price Is. 6d. 
cloth. Is. paper wrapper. 

"Tho little book la weUdana."-ia™«!. 

Anatomy. Text Book of Anatomical Plates, designed under the 
direction of Professor Masse, with descriptive Text. By 
Ja.'5. Cantlie, M.B., CM. (Honours), F.R.C.S., Assistant Sur- 
geon to Charing Cross Hospital. New edition. {In the press.) 

Anatomy. The Essentials of Anatomy. Designed on a new and 
more easily comprehensible basis, as a Text-book for Students, 
and as a book of easy reference to the practitioner. By W. 
Daktjng, M.D., F.RC.S., and A. L. Ranney, M.D. 12s. 6d. 

riaing, ara the results of long aiBeriBnce In the teaching of rtudsDla ; theaa giia the hook 1 



8 



Baillifere, Tindall, and Cox's Books. 



Aoatomy. Human Anatomy and FbysiologTi illustrated 

by a Beriea of Movable Atlases of tlie Human Body, showing 
the relative positions of the several parts, by means of Superposed 
Coloured Plates, from the designs of Prof. G.J.WlTK0W8Kl,M.D. 
Each part complete in itself. 

%" A Companion to every work on Anatomy and Physiology. 

Part I.— Neck and Trunk. With Text Descriptive and Ex- 
planatory of the physiology and functions of tho several parts. 
By Robert Hunter Semple, M.D., F.R.C.P.,Lond. Price 7a. 6d. 

Part II. — Throat and Tongue, showing the Mechanism of 
Voice, Speech, and Taste. Text by Lennox Browse, F.RC.S. 
Edin. Price 7a. 6d. 

Part III. — The Female Organs of Generation and Keproduo 
tion. Text by James Palfrey, MD., M.E.C.P. Lond., late 
Senior Obstetric Physician, London Hospital. Price 7b. 6(1. 

Part IV. — The Eye and the Apparatus of Vision. Text by 
Henry Power, F.R.C.S., Senior Ophthalmic Surgeon to St 
Eartholomew's Hospital. Price 7s. Gd. 

Part V. — The Ear and Teeth. The Mechanism of Hearing 
and of Mastication. Text of the Ear by Lennox Browne, 
F.R.C.S. E. The Teeth by H. Sewill, M.RC.S. Price 7a. 6d. 

Part VI.— The Brain and SkuU. (Cerebrum, Cerebellum, 
and Medulla Oblongata). Text by T. Stretch Dowse, M.D., 
F.R.C.P. Edin., formerly Medical Superintendent of the Central 
London Sick Asylum. Price 7s. 6d. 

Part VII.— The Male Organs of Generation. Text by 
D. Campbell Black, M.D., Physician to the Glasgow Hoyal 
Infirmary. Price 7e. 6d. 

Part VIII. — The Skeleton and its Articulations, showing the 
Bones and Ligaments of the Human Body and Limbs. Text by 
A. T. Norton, F.E.C.S., Surgeon to an<l Lecturer on Surgery 
at St. Mary's Hospital, London. Price 7s. 6d. 

Part IX. — The Hand; its Bones Muscles and Attachments. 
Text by Jas. Cantlie, MB., F.E.C.S., Assistant Surgeon, 
Charing Cross Hospital. Price 7s. 6d. 

Part X. — The Foot; its Bones Muscles and Attachments. 
Text by Stanley Boyd, M.B., B.S., Lond., F.E.CS., Assistant 
Surgeon, Charing Cross Hospital. Price 7s. 6d. 

*,* No aaoh simple, reliable, and comprehensive method of learning the 
several parte, ^OBitiona, and functions nf the body lias hi tberto been attempted; 
the entire Series being uniijue, will be moat valuable to the Teacher, the 
Stadeut, and to all who wish to become acqaainted with the anatomy and 
physiology of the human ecooomy. 



Bail lifere.Tindall, and Cox's Books. 9 

Anatomy. The Pocket Gray, or Anatomist's Vade-Meoum. Com- 
piled epeciaUy for Students from the works of Gray, Eilis, 
Holdea, and Leonard. Fourth thousand. Price 2a. 6d. 

Anatomy. Schematic Anatomy ; A new, easy, and more 
certain method of treating the Association and Schematic 
arrangement of Structural Details of Human Anatomy. By 
William P. Meaks, M.B., Professor of Anatomy and Examiner 
in Anatomy at the University of Durham. Profusely illustrated- 
Price 78. 6d. 

AnatomOjgraphy ; or, Graphic Anatomy. A new method of 
grasping and committing to memory the most difficult points 
required of the student, ByW. Darling, M.D.,r.RC.S. Eng., 
Professor of Anatomy in the University of New York. Second 
edition. Price Is. 

Apoplexy. Diagnosis and Treatment of Apoplexy. By T. Stretch 
Dowse, M.D., F.R.C.P.E., formerly Medical Superintendent, 
Central London Sick Asylum. Price Is. 

Army Hygiene- Lessons in Military Hygiene and Surgery. By 
Surgeon-General Gordon, M.D., C.B., Hon. Physician to H.M. 
the Queen. Illustrated. Price 10s. 6d. 

Artistic Anatomy. Anatomy of the External Forms of Man, 
designed for the use of Artists, Sculptors, etc. By Dr. J. Fau. 
Used at the Government School of Art, South Kensington. 
Twenty-nine plates. Folio ; New edition shortly. 

Artistic Anatomy. Elementary Artistic Anatomy of the Human 
Body. From the French of Dr. Fau. With English Text. Used 
at the Government School of Art, South Kensington. Price 5s. 

Artistic Anatomy. Elementary Anatomical Studies of the Bones 
and Muscles, for the use of Students and Schools, from the 
drawings of J. Flaxman, R.A. Lately used as a Tcxtrbook of 
Anatomy in the Art Schools at South Kensington. 20 plates, 
with Text, price 2s. 

Artistic Anatomy. The Student's Manual of Artistic Anatomy. 
"With. 25 etched plates of the bones and surface muscles of 
the human figure. By W. J. Muckley, Principal of the 
Manchester School of Art. Used at the Government School of 
Art, South Kensington, Second edition. Price 5a. 6d. 

Artistic Drawing. Second Grade Perspective (Theory and Prac- 
tice), containing 21 block illustrations, 12 well-executed plates 
on Parallel and Angular Perspective, and many examination 
exercises. Used at the Government Science and Art Schools, 
By H, J- Den.-JIS, Art Master, Lambeth School of Art, Dulwich 
College, etc. Fourth edition, price 2a. Cd, 






10 BailHer«, Tindall. and Cox's Books. 

ArtlBtic Dr A w i ng. Thinl tinde P<rqMctiTe, compmuig J 
tad OUiqoe PenpeetirB, Skadon and Beflectioas, s[^ 
|M«paredror UKOWof Azt StndeBts. Bj R J. Dexkis. JJat. 

at the Gorenuneiit SeJencv «ad Art Scfac»oI&. Fifth editjn 

la two pule 7e. fid. each. Put 1, Angular uid Obtiqoe. Patt 
2, SkadovB aod Reflections. 

Artistic Drainil£- The Prototype of Msn, giring the natnnl laws 
of Haman proportioD in boUi sexes, A msna&l for Artists and 
professors of drawing. B/ Chas. Eochet, of Paris. Price Is. 

Artists' Colours- Their Prepar^on, Uses, etc By the same 
Author. (See Colonrs.) 

Art Students' Physiolc^y. By R Thompson Lown-b, F.R.C.S.. 
Examiner in Physiology, Royal Collie of Surgeons. Second 
thousand. Price 2s. 

AsthnUi' On Bronchial Asthma — its conises, Pathology and Treat- 
meut Being the Lettsonnisn Lectures delivered before the 
Medical Society of London. By J. C. Thorowgood, M.D., 
F.R.C.P. London, Senior Physician to the City of London 
Hospital, for Diseases of the ChesL Secoud edition. Price 2s. 6d. 

Astronomy. The Stars and the Earth ; or. Thoughts on Time 
Space, and Eternity. ReTised and enlarged, with Notes by 
li. A. Pkoctor, B.A, Hon. Sea to the Royal Astronomical 
Society. Fourteenth thousand, price Is. 

Atlases- A Series of Movable Atlases afaowing the relative position 
of the several parts of the Human Body by means of super- 
posed coloured plates, from the designs of Prof. G. J. Wit- 
Kuwsiil. (See Anatomy.) 

Ataxia. Nervous AfTectiona associated with the Initial or Curative 
Stage of Locomotor Ataxy. By T. Stretch Dowse, MD., 
F.Ii.C.P.E. Second edition, price 2s. 

Bladder. On Diseases of the Bladder, Prostate Gland, and tJrethca 
By F. J. Gant, F.R.C.S,, Senior Surgeon to the Royal Free 
Hospital. Fifth edition. Price 12s. fid. 

Aids to Botany. Outlines of the Elementary Facts, in- 
cluding a Description of some of the moat important Natural 
Onlers. By C. E. Armanu Semple, B.A., M,B, Cantab., 
M.R.C,P. Lond., Examiner in Arta at the Apothecaries' HalL 
Third thousand. Price 28. 6d. cloth ; 2a. paper wrapper. 

Botany. A System of Botanical Analysis, applied to the Diag- 
nosis of British Natural Orders. By Handsel Griffiths, 
Ph.D., M.R.C.P., late Professor of Chemistry in the Ledwioh 
School of Medicine. Price la. 6d. 

"Tha muUior bu plneid the studsnt imdor coi»liicmbls Dhligitbns b; Ms eyatom al 
botuiliail lumlyals."— Atonnacnilieil Jmrnal. 



I 

I 



Baillifei'e, Tindall, and Cox's Books. 11 

BotaJiy. A Dictionary of British Plants and Flowers ; their names, 
pronunciation, origin, etc. By H. P. Fitzgerald. Price 2s. 6d. 

Brain. Tlie Building of a Brain. By E. H. Clarke, M.D. (author 
of " Sex in Education "). Price 5s. 

" We ara much ploLBod with the Uttle work, which is carefully (md Blogpmtly writtfln, and 
tall of sound physiology."— iuncff. 

Brain. The Physiological and Chemical Constitution of the Brain, 
based throughout on original researches. By B. J. L. W. 
Thudichum, M.D.,F.R.C.P., London, President of the West 
London Medical Society. Price 10s. 6d. 

Brain. The Brain and Diseases of the Nervous System. 2 vols. 
By T. Stretch Do\vse, M.D., F.E.C.P. Ed., formerly Medical 
Superintendent of the Central London Sick Asylum. 
VoL I. SyphUisof the Brain and Spinal Cord, showing the part 
which this agent plays in the production of Paralysis, Epilepsy, 
Insanity, Headache, Neuralgia, Hysteria, and other Mental and 
Nervous Derangements. Second edition, illustrated, price 7s. 6d. 
Vol. II. Neuralgia : its Nature and Curative Treatment. Price 
7s. 6d. 

Brain. The Brain and the Nerves, their Ailments aod their Ex- 
haustion, by the same author. Price 3s. Gd. 

Brain. Responsibility and Disease : Moot-points in Jurisprudence 
about which Medical Men should ba well instructed. By J. H. 
Balfour Browne, Barrister-at-Law, author of " The Medical 
Jurisprudence of Insanity," Price 2s. 

Breath. The Breath, and the Diseases which give it a Fcetid Odour. 
By J. W. Howe, M.D., Professor of Surgery in the University 
of New York. Price 4s. 6d. 

Bronchitis. Chronic Bronchitis : its Forma and Treatment. By J. 
MiLNER FoTHERGiLL, M.D. Edin,, MR.C.P. Lend. Price 4a. Gd. 

*' TliB pag:oa toom wlEh duggefltioiifl of v^lIuo." — PhiiiukCpiiia Jitdiatt Times. 

Bnrmah. Our Trip to Burmah, with Notes on the Ethnology, 
Geography, Botany, Habits and Customs of that Country, by 
Surgeon-General Gordon, C.B., M.D., Physician to the Queen. 
Illustrated with numerous Photographs, Maps, Coloured Plates, 
and Sketches in gold by native Artists. Price 21s. 

countrj.'-mt !•.««. 

Case-Books. Students' Case-book. For recording hospital cases 
as seen, with full instructions for methodising clinical study. 
By George Brown, M.E.C.S., Gold Medalist, Charing Croas 
Hospital, late Demonstrator of Anatomy, Westminster Hospital. 
Third thousand, price Is., cloth limp. 



lii 



12 Baillifere, Tindall. and Cox's Books. 

Case-Books. Forms for the taking of Aural Cases. By Lennox 
Browne, F.R.C.S. Ed., Senior Surgeon to the Central London 
Throat and Ear Hospital. 25 in boards, price 2s. 

Forms for the taking of Throat Cases. 25 in boards, price 2a. 

Throat and Ear Cases. 50 in boards, combined, price 3s. Gd, 

Case-Books. Note-book for Stndents beginning the study of 
disease at the bedside. By Jas. Little, M.D., Univ. Dub, 
Third edition, price 3s. Gd. 

Chemistry. Aids to Chemistry. By C. R Afm.ind Semi'LE, B.A,, 

M.B. Cantab., M.K.C.P. Lond. 
Part I. — Inorganic. The Non-metallic Elements. Price Is. 6d,, 

cloth ; la. paper wrapper. 
Part II.— Inorganic. The Metals. Price 38. Gd,, cloth ; 3s. paper. 
Part 1 1 1. ^Organic. Cloth, 2s. Gd. ; paper, 3b. 
Part IV.--Tablets of Chemical Analysis. Price Is. 6d. and Is. 

"atudent* prBparlng for Mutridutntion nt Ihe iJjndon UnlTcnily, and other Eauminiitiona 

Ohemiatay. A Manual of Chemistry; a coraplete guide to 
Lectures and Laboratory work for beginners in Chemistry, and 
a text-boob for students in Medicine and Pharmacy, By W. 
SraoN, Ph.D., M.D., Professor of Chemistry and Toxicology in 
the College of Physicians, and Professor of Analytical Chemistry 
in the College of Pharmacy, Battimora Sixteen woodcuts, and 
seven coloured plates representing fifty-six Chemical reactions. 
Demy 8vo. Price 15s. 
Chemistry. Chemical Notes and Equations: for the use of 
Students. By K Milne Murray, M.A., M.B., CM. Edin. 
Price 2s. 
Chemistry. Chemistry in its Application to the Arts and Mana- 
factures. A Text-book by Kichardson and Watts, 
Vol, L : Parts I and 3. — Fuel and its Applications. 433 engrav- 
ings, and 4 plates. Price £1 16s. 
Part 3.— Acids, Alkalies, Salts, Soap, Soda, Chlorine 
and ita Bleaching Compounds, Iodine, Bromine, 
Alkalimetry, Glycerine, etc., their Manufacture 
and Applications, price £1 13s. 
Part 4. — Phosphorus, Mineral Waters, Gunpowder, Oun- 
cotton, Fireworks, Aluminium, Stannates, Tung- 
states, Chromates and Silicates of Potash and 
Soda, Lucifer Matches, price £1 Is. 
Part 5. — Pi'usaiate of Potash, Oxalic Acid, Tartaric 
Acid, many tables, plates, and wood engrav- 
ings, price £1 10s, 



Baillifere, Tindall, and Cox's Books. 13 

Ohemistrj. Practical Treatiae on Acids, Alkalies, ami Salts : their 
Manufacture and Application. In three vols., being Parts III., 
IV., V, of the previous work, price £i 10a. 

Ohemiatry. The Principles of Theoretical Cbemistry, with special 
reference to the CoasEitutrion of Chemical Compounds. By Ira 
Remsen, M.D., Ph.D., Professor of Chemistry in the John 
Hopkins University. Second Edition, revised and enlarged. 
Price 7s. 6d. 

Chemiatry. The Student's Hand-book, with Tables and Chemical 
CalciUations. By H. LEICESTER Greville, F.I.C, F.C.S, 
Price 9s. 

Chemistry. Chemical Notes for Pharmaceutical Students, including 
the Chemistry of the Additions to the Pharmacopceia. By 
A, ItrvKRa WiLLSON. Price 2s. 6d. 

Chemistry. An Introduction to Analytical Chemistry for Labora- 
tory Use. By John Muter, Ph.D., M.A, F.C.S., President of 
the Society of Public Analysts. Second edition, price 7s, 6d. 

Ohemistry, An Introduction to Pharmaceutical and Medical 
Chemistry, Theoretical and Practical, With Analytical Tables 
and copious Index. By the same Author. Price lOs. 6d. 

' Ths book Is iiag of a vqtj- iiaef ul and original kind, and iD br-oufllit up to thfl latfiat date, 
testa proce&tics publlalufd 0UI7 a fuw montiia dLnca boiuf f uUy Aeat^lb&d."^Cheiiii6ai Netca. 

Children, The Diseases of Children their History, Causes ami 
Treatment. By C. E. Armand Semple, B.A, M.B, Cantab., 
M.R.C.P. Lond., Pliysictan to the North-Eastern Hospital ior 
Children. Price 6s. 

Children- Lectures on the Diseases of Children delivered attho 
Hospital for Sick Children. By Robert J. Lee, M.D. Cantab., 
P.RC.P., Lond., Assistant Physician to the Hospital. Second 
edition, enlarged. Price 3s. 6d. 

CSlildren. On Tetany in Young Children. By J. AUERCROMBIE, 
M.D., M.R.C.P. Lond. Price 23. 

China. Reports of the Medical Officers of the Chinese Imperial 
Maritime Customs Service, from 1871 to 1882, with the History 
of Medicine in China. Compiled by Surgeon -General Gordon, 
M.D., C.B-, Physician to Her Majesty the Queen. Price 21s. , 

Cholera. Cholera : how to Prevent and Resist it. By Professor 
VON PE'n'ENKOFER, University of Munich, President of the 
Sanitary Department of the German Empire ; and Thomas 
Whiteside Hime, A.B., MB., Medical Officer of Health for 
Bradford. Second edition. Illustrated. Price 3a. Cd. 



14 Baillifere, Tindall, and Cox's Books. 

Cholera The Cholera Microbe and How to Meet It. Eead at 
the Congress of the British Medical Association at Belfast, July, 
1884. By Chakles Cameros, M.D., LL.D., M.P. Price Is. 

Clinical Charts for Eecording the Range of Temperature, Pulse, 
Respiration, History, Progress, and Treatment of Caaea, for 
use in Hospitals and in private practice. By K W. MooRe, 
M.D., M.E.C.P. Price Id. each, 9d. per dozen, ormoiinted, 
similar to a blotting-pad, in 50, 38. 6d.; 100, 78. 

Colotirs. A Hand-book for Painters and Art Students, on the use 
of Colours, Vehicles, etc. By W. J, MuCKLEY, Principal of 
the Manchester School of Art. Third edition, price 3a. 6d, 

Oonsumption. Consumption, as a Contagious Disease, with Treat- 
ment : including an Inquiry into the Relative Merits of the Air 
of Mounldna and Plains; to which ia prefised a translation of 
Cohnheim's Pamphlet. By D. H, CULLIMORG, M.K.Q,C.P., 
r.K.C,S.I., formerly Surgeon H.M. Indian Army. Pnce 5b. 

Consumption. Consumption and its Treatment by tlie Hypophos- 
phitea. By John C. Thoeowgood, M.D., F.R.C.P. Lood., 
Physician to the City of London Hospital for Diseases of the 
Chest, Victoria Park. Third edition, price 2a. fid. 

Consumption. Consumption, its True Nature and SucceBBfnl 
Treutiiient, with Appendix of Cases. By Godwin Timms, 
M.1). Loud., M.R.C.P., Senior Physician to the North London 
Oonsumption Hospital, Consulting Physician to the Westeni 
City Dispensary, etc. Second edition, price lOa. 6d. 

Consumption. How to Prevent and Treat Consumption. By G. 
Rutland Howat, B.A Lond., L.E.C.P. Ed., M.E.C,S, Eng. 
Cloth Price -20. 6d. 



Consumption. A lie-investigation of its Causes, showing it to 
arise from an Excessive Action of Atmospheric Oxygen, Its 
Dietetic, Climatic and Therapeutical Treatment. By C. W. 
De Lacy Evans, M.R.C.S. Eng. Price 2s. 6d. 

Consumption. Tuberculosis from a Sanitary and Pathological 
Point of View, By G, Fleming, F.R,aV.S., President of the 
Royal College of Veterinary iSurgeons. Price Is. 

Deafness. (See Ear.) 

Deformities. Tiie Nature and Treatment of Deformities of the 
Human Body. By Lambert H, Ormsbt, M.B. Univ. Dub., 
Surgeon to the Meath Hospital and County Dublin Infirmary. 
Crown 8vo., illustrated, price 5s. 



! 



Baillifere, Tindall, and Cox's Books. 15 

DeELf-miltisni. On the Education of Deaf-mutes by Lip-Reading 
and Articulation. By Professor Hartmakn, Translated by 
Dr. Patterson Cassells. Price Ta. 6d. 

Biagnosis. 

Part L- — Aids to Semeiological Diagnosis, By J. Milner 
FoTHERGiLL, M.D., M.KC.P. Lond.. Physician to the City of 
London Hospital for Diseases of the Chest. Price Is. and Is. 6d. 

Part IL — Aids to Physical Diagnosis. By J. C. Thobowoood, 
M.D., F.B.C.P. Lond., Physician to the City of London Hospital 
for Diseases of the Chest, Lecturer on Materia Medica at 
Middlesex Hospital. Price Is. and Is. 6d. 

Part III. — What to Ask. By J. MiLNER Fothergill, 
M.D., M.R.aP. Lond. Price la. and Is. 6d. 

" A mine of Tsluable informattDn."— £i2in£iii^& lledaal Ja^nmL 

Dlagaosis. The Physiological Factor in Diagnosis. By the same 
Author. Second Edition. Price 7s. 6(1. 

McKl, and taking vaj r—Sdm}nL^s,h Mediail Jfunal. 

Diphtheria. Diphtheria, its Causes, Pathology, Diagnosis, and 
Treatment. By R. Hunter Semplb, M.D., F.E.C.P. Lond., 
Physician to the Hospital for Diseases of the Throat and Chest. 
Second edition, price 3s. 6d. 

"It la aatiafactory to know that Ihe dootrinea laid down by UienuUior, mciny j-earaago, do 

Domsstic Medicine. Handbook of Popular Medicine for family 
instruction ; for colonists and others out of reach of medical aid. 
By G. H. Napheys, A-M., M.D. With movable plate and 
100 illustrations. Price 7s. 6d. 

Opinion, 

Drugs. The Specific Action of Drugs, an Index to their Thera- 
peutic Value, as deduced from experiments on man and animals. 
By A. G. BUKNESS, M.D., and F. Mavor. Price 10a. 6d. 

Ear. On Diseases of the Ear their Diagnosis and Treatment. By 
Oren D. Pomerot, M.D., Surgeon to the Manhattan Eye and 
Ear Hospital, New York, etc. In one handsome 8vo. volume 
of over 400 pages, profusely illustrated, cloth. Price 12a. 

Ear. Text-book of the Diseases of the Ear and adjacent Organs. 
By Professor Poi.ITZER, of Vienna. Translated by James 
Patterson Cassells, M.D., Consulting Physician to the 
Glasgow Ear Infirmary. 800 pages, with 257 original illustra- 
tions. Price 21a. 

. CsbsbUb hsH done gond aorrico to English raadora, hj turnlnTiIng tliem with ao oiecUont 



'' Tha work of a reuogidfiod 
" WUl take rBok „s tho stai 



idard hook ol refen 



16 BEulli^re, Tindall, and Cox's Books. 

Ear. Otoirhcea ; or, Discliarge from the Ears : its Varieties, Cauaea, 
Complications, and Treatment. By W. Douglas Heuuinu, 
F.R.C.S. Ed. Price Is. 

Etiquette. A few Rules of Medical Etiquette. By a L.E.C.P. 
Loud. Price Is. 

Esaminations. Aids to Examinations. By W. DoOGLAS Hem- 
ming, F.R.CS. Ed., and H. Aubrey Husband, M.B., F.R.C.S. 
Being Questions and Answers on Materia Medico, Medicine, 
Midwifery, Pathology, and Forensic Medicine, Third thousand. 
Price Is. 6d, cloth, la, paper wrapper. 

Examinations. A Guide to the Esaminationa at the Royal College 
of Surgeons of England for the Diplomas of Member and 
Fellow, with Examination Papers. By F. J. Gant, F.K-C.y., 
Author of the " Science and Practice of Surgery." Fourth 
edition, revised and enlarged. Price 48, 6d, 

Examinations. A Guide to the Examinations of the Apothecaries' 
Society. By W. E. Dawson, L.S.A. Price 2a. 6d. 

'*Uay be qbiiiod with greaX advantage by c student, ahottly before proacndng blmBolf for 



^ 



Examinations. Examination Questions on tbe Medical Sciences, 
including the Army, Navy and University Examinations. 
Selected and arranged by James Greig Lease, M.B. Abdn. 
Second edition. Price 23. 6d. 

"nr. LcABlc'a qiiestioiia orB paHlciilarly fiultable for pure oxaialuBtluti study. Students 
iihoold toat themdelvea tbnreby.^'— Siilii). Jlidical /niimnl. 

Eye. A Manual of Opbtbalmic Practice. By R C. ScHKLL, M.D. 
Ophthalmic Surgeon to the Children's Hospital, Philadelphia, 
with 53 illustrations. Price 9s, 

Eye- The Cure of Cataract and other Eye Affections, By Jabez 
Hogg, M.R.C.S., Consulting Surgeon to the Royal Westminster 
Ophthalmic Hospital. Thu^ edition. Price 2s. 6d. 

Eye. On Impairment or Loss of Vision from Spinal Concussion or 
Shock. By the same Author. Price Is. 6ct. 

Eye. The Functions of Vision and its Anomalies. By Dr. Giraud 
Teulon, Member of the Academie de Medicine. Translated 
by Lloyd Owen, F.R.C.S.I., Surgeon to the Birmingham and 
Midland Eye Hospital, Ophthalmic Surgeon to the Free Hospital 
for Sick Children, Birmingham. Illustrated, price 5s, 

Eye. Movable Atlas of the Eye and the Mechanism of Vision. 
By I'rof. G. J. AVriKOWSKi. Price "b. 6d. (See Anatomy.) 

Fasting and Feedings, Psychologically considered. By L. S, 
Forbes AVinsloVi', M.B, Cantab,, D.C.S. Oxon. Price 2s. 



Baillifere, Tindall, and Cos's Books. 17 

y&ver. On the Endemic Hfematuria of Hot Climates, caused by 
the prasenoe of Bilharzia Hfematiiria. By F, H. H, Guillemaed, 
M.A., M.D., F.R.G.S. Price 2s. 

Food. Food ; its Varieties, Chemical Composition, Nutritive Value, 
Preparation, Preservation, Adulterations, etc. By the late Dr. 
LETaEBT, Secoad edition, enlarged, price 5s, 

" Dr. Lotheby's poaf Hon unci authority on tho subjaot of iood is so pre-omioent, that s. boole 

" EEtJiBr as a, teit-bonk for schools or ofl a liouaehold ^nldo, tt tfl eicellentLj adapted."— 
1*1.6; «; OpUim. 

Food- Aids to tho Analysis of Food and Urugs, By H. Aubrey 
Husband, M.B., F.E.C.S., Lecturer on Public Health, in the 
Edinburgh Medical School. Price la. 6d., cloth; Is. paper. 

Food. The Healtby Manufacture of Bread. ByB. W. Kiohardson, 
M.D., F,E.S. Price 6d., paper cover ; cloth Is., with Vignette. 

" Tbo Diniftiflh nystom Is tha cleanest procesa IcDowu, calls for lasa drudgerr, less ubjectlau- 
ablo labour, and Hupplies a. purer artide."— Pr^/ow. 

Foot. Movable Atlas of the Foot; its Bones, Muscles aod 
Attachments. By Prof, WiTKOWSKr. Price Ts. 6d. (See 
Anatomy.) 

Forensic Medicine. The Student's Handbook of Forensic Medicine 
and Medical Police. By H. AUBREY Husband, M.B., F.E.C.S, E, 
Fourth Editioa Price 10s. 6d. 

Forensic Medicine. Aids to Forensic Medicine and Toxicology. 
ByW. DoUGLAsHEMMiNG,F.E.C.S.E,andH. Aubrey Husband, 
M.B., F.E,C.S.E. Third thousand, price la, 6d. cloth, Is. paper. 

" Wa ha.o no hosititlon in recommending Mr. Hemming^e boof'-iminf. 

Geology. Field Geology, with a Section on Palseontology. By 
W. Hy. Penning, r.G.S., of HM. Geological Survey, and 
A J. Jukes-Browne, B.A, F.G.S. With woodcuts and 
coloured map. Second edition, revised and enlarged, price 7s. 6d. 



(JeologV- Engineering Geology. By the same Author. Illustrated 
witn coloured map and woodcuts, price 33. 6dl 



Gout. A Treatise on Gout, By Austin Meldon, M.K.Q.C.P., 
F.E.C.S.L, Senior Surgeon to Jervis Street Hospital, Consult- 
ing Physician to the Dublin General Infirmary. {In Ihe Press.) 



18 BailHfere, Tindal!, and Cox's Books. 



Oymnastics. A Short Sketch of Bational Medical Gymnastics ; 
or, the Movement-Cure. By B. M. Roth, M,D., F.R.C.S. Eng. 
With thirty-eight engravings, price Is. 

The Prevention and Cure of Many Chronic Diseases liy Move- 
ments. By the same Author. With 90 engravings, price 10a. 

The Hand-book of the Movement-Cure. By the same Author. 
With 155 original engravings, price 10s. 

Contribution to the Hygienic Treatment of Paralysis, and of 
Paralytic Deformities. By the same Author. With 38 en- 
gravings, illustrated by numerous cases, price Ss. fid. 

On Paralysis in Infancy, Childhood, and Youth, and on 
the Prevention and Treatment of Paralytic Deformities. Sa. 6d. 

The Prevention and Rational Treatment of Lateral Spinal Cur- 
vature. (To which was awarded the Gold Medal of the Inter- 
national Health Exhibition, 1884.) By the same Author. 
With nearly 200 engravings. Price 5a. 
Gynaecology- The Diseases of Women and their Treatment By 
H, MA.JNAUGHTON JoNES, M,D,, F.R.C.S.I., F.R.C.S.E., Pro- 
fessor of Gyniecology in Queen's College, Cork, Examiner in 
Midwifery, Eoyal College Surgeons, Ireland. Second edition. 
Illustrated, price 7s, Gd. 
Gynecology. A Manual of the Minor Gynrecological Operations 
and Appliances. By J. Halliday Ckoom, M.D., F.E.C.P., 
F.R.C.S.E., Lecturer on Midwifery and Diseases of Women at 
the Edinburgh School of Medicine, Second edition, with 12 
plates and 40 woodcuts, price Gs. 

GynBecology. Lessons in Gyniecology and Obstetrics, By 
W. GooDELL, AM., M.D., Professor of Clinical Gynscology in 
the University of Pennsylvania. Second edition, with 92 
illustrations, price ISs. 

GynBBCology, Aids to Gynfficology. By Alfred S. Gubb, 
M.R.C.S., L.R.C.P., Obstetric Assistant and Gold Medallist 
Westminster Hospital. Price Is., cloth Is. 6d. 

Hay Fever ; its Causes, Treatment, and Effective Prevention ; Ex- 
perimental Researches. By Chas. HARRISON BlACKLEY, M.D. 
Second edition, revised and enlarged, price lOs. 6d. 

" A i^ecfl of Teal honest work, original and InntructWo." — Lanett, 

'' Wq TODommBiid It cdrdfally to all vbo mAy wlbh Far a. practical work on thib oncd mya- 
tBrious aimane."— «o*i<Dl Tima. 

Hand. Movable Atlas of the Hand ; its Bones, Muscles and Attach- 
ments. By Prof. WiTKOwsKi. Price 7s. 6d. {See Anatomy.) 

Heart. On Insufficiency of Aortic Valves in Connection with Sudden 
Death. By John Cockle, AM., M.D., F.RCP., Physician to 
the Royal Free Hospital. Second edition, price 2s. fid. 



Baillifere. Tindall, and Cox's Books. 19 



Heart. An Essay on Fatty Heart. By Henry Kennedy, A-B., 
M.B. Physician to the Wbitwortli Hospitals. Price 3s. 6d. 

at theall-imiKirtaut subjact of which it trsstB."— JTBiicol Prat. 

Histology. Introduction to Practical Histology. By George Thin, 
M.D. Price 5s. 

Hygiene. Lessons in Military Hygiene and Surgoiy, from the 
Franco-Prussian War. Prepared on behalf of Her Majesty's 
GoTernment. By Surgeon-General Gordon, M.D., C.B., Hon. 
Physician to the Queen. Illustrated, price 10s. 6d. 

" A treatiae pf oxiwptlanal morit, drawn from pereanal exiMiricniHfl in thu groateet war of 
modern times, "—Jrrny ind ya^--; da&tU. 

Hygiene. A Manual of Sanitation ; or, First Help in Sickness and 
when Wounded. A pocket companion for the army and 
volunteers. By the same Author. Second edition, price, cloth, 
28. 6d., or cheap edition, paper wrapper Is. 

" It ia a most useful nnd praotioal manual, and, bs the ii]BtraE:tiDii& are aimplu and Tollable, 
It Bboiild be placed in the banda of u^cara and men hIiIcb." — The ilr^phic. 

Hygiene. Nature's Hygiene : a Systematic Manual of Natcral 
Hygiene, including Ventilation, Oxidation, Putrefaction, 
Chemistry of Atmosphere, Water Supply, Sewage, Micro-organ- 
isms, Fevers, Disinfectants, etc. By C. T. KlNGZBTT, F.l.C, 
F.C.S. Second edition. Price 7s. 6d. 

Hygiene. Healthy Homes. By Stanley Haynes, M.D., M.E,C.S., 
F.R.G.S. Price Is. 

Hygiene. Notes on Nuisances, Drains, and Dwellings. ByW. H. 
Penning, F.G.S. Second edition, price 6d. 

Hygiene. Short Lectures on Sanitary Subjects. By EiCHARD J. 
Halton, L.K.Q.C.P., L.E,C.P. Ed., L.R.C.S.L, etc., Medical 
Officer of Health to Kella. Price 5s. 

"A book woU adapted to popular raiding, and reploto with Bound lEnowledge promotive of 
food health and long life. " — StinifiTian. 

Hygiene. A Manual of Naval Hygiene, with Instructions and 
Hints on the Preservation of Health and the Prevention of Disease 
on board Ship. By Joseph Wilson, M,D., Medical Director 
of the United States Navy. Second edition, price 10s. 6d. 

Hygiene. The Sanitation of Public Institutions for the preserva- 
tion and improvement of the Health of the Inmates of Schools, 
Prisons, Workhouses, Hospitals, etc. The Havard Gold Medal 
Prize Essay, 1884. By R. D. E. SwEETlNfi, M.E.C.S., Medical 
Superintendent of the Western Fever Hospital Price 3s. 6d. 



20 Baillifere, Tindall, and Cox's Books. 

Insanity- The Diagnosis, Classification, and Treatment of Insanity : 
A Manual for Students and Practitioners of Medicine. By E. C. 
Spitzka, M.D. President of the New York Neurological 
Society, etc. In one handsome 8vo. volume of nearly 425 pages, 
illustrated, cloth, price 12s. 

"OrlginiU ami paliutoklnKa* overjthliiK U "rhlah Proteanor Hpitika undortakM."— Af<ii«if 

laternationaJ MediCEll Congress- The Commemorative Portrait- 
Picture of the International Medical Congress, 1881. By Mr. 
Barraud. This Picture, illustrating the most memorable 
gathering of Medical Men in the world's history, designed and 
executed by Mr. Barraud, contains nearly 700 Likenesses of 
Members of the Congress, representing Medicine and Sai^gery 
in every part of the world, special sittings having been accorded 
for every Portrait. 



FOFDLiR aiZB, 2H X aO, Muustid, blt Uskbauid ; 

[ur by U wus uhulnod " a larger iutcreoursij dad dlfliuioD of inlnmmtiuii than in any »qiiU 
tiioe and spaup In the whole hlalcry al Medicine." 

Kidneys. Bright's Disease of the Kidneys. By Professor J, M, 
Charcot. Translated by H. B. Millard, M.D., A.M. Ee- 
vised by the Author, vpith coloured plates, price 7s. 6d. 



oticiaBly dflBcribed."— Jfe 



a|>b in which the 



Lunacy. Handbook for the Instructions of Attendants on the 
Insane. Prepared by a Committee of the Medico-Psychological 
Association. Price Ss. 

Lunacy. Handbook for Attendants on the Insane ; instructions for 
the managemeot, artificial feeding, and mechanical restraint of the 
insane; legal documents required for their confinement, etc. 
By L. S. Forbes Winslow, M.B,, D.C.L. Oxon. ; M.R.C.P.; 
Lecturer on Mental Diseases, Charing Cross Hospital. Price 1b. 

Lunacy. A Lunacy Chart : a Synopsis of the Lunacy Acts, mth 
special reference to the management and care of persons of 
Unsound Mind. By the same Author. Price Is. 6d., ramiahed 
and mounted on rollers, 43. Gd, 

Lunacy. Spiritualistic Madness. By the same Author. Price Is. 

Materia Medica' Note-Book of Materia Medica and Therapeutics. 
By R. E. Sooresby-Jaokson, M.D., F.E.S. Ilerised by 
Angus Macdonald, M,A, F.R.S. Third edition, price 12a. Cd. 

"A wiirk wflcan recemmoad wiUithQutmotit fvuifldfiliee." — Studtntu' Ji}}-y}iuf- 



i 

i 



Baillifere, Tindall, and Cox's Books. 21 

Materia Medica- A Key to Organic Materia Medica. By JoHN 

Muter, Ph.D., M.A., F.C.S., President of the Society of Public 
Aoalysta. Third edition, price i2s. 6d. 

Materia Medica- Aids to Materia Medica and Therapeutics. 
Part I. — Tlie Non-metallic and Metallic Elements, Alcoholic aod 
Ethereal Preparations, etc. By C. E Arm.\ND Semple, B.A., 
M.B. Cantab., M.E.C.P, Lond. New edition in preparation. 

Part II. — The Vegetable and Animal Snbatances. Double Part, 
price, cloth 2g. tid., paper 2s. 

Part III.— Tablets of Materia Medica. Price, cloth Is. Gd., 
paper Is. 

Materia Medica and Pharmacy. A Text^Book fur Medical and 
Pharmaceutical Students preparing for Examination. By W. 
Handsel Greffiths, Ph.D., F.C.S., F.E.C.P. Ed. Edited by 
George F. Duffey, JI.D. Dub., Fellow and Examiner K.Q.C.P., 
Examiner in Materia Medica, Queen's University, etc Price 9s. 

" A book af gnat valua .... nBtaadard taiiX-hoali:^"— EdiiL HeiL Jaiin}al. 

'^Oub of Uie ublBst, tf not the beat, work on thoHubJout In our language. "^J/i^L t^ent. 

Medical Education. Medical Education and Organization. The 
Hunterian Oration for 1880. By Waltee Kivington, B,A., 
M.B., F.K.C.S., Surgeon to the London Hospital. Price la. 

Medical Etiquette- 7'A Few Rules of Medical Etiquette. By a 
L.K.C.P. Lond. Price la. 

Medical Laws. The Laws Belating to Medical Men. By James 

Greenwood, Barrister-at-Law. Price Cs. 

•' Wo BipECt that It wlU meet with Cho suooess which It rcully ilnnervoa.-'—JJinim-;* AfeduoJ 



Medical Profession. A Guide to the Medical Profession in all its 
branches, including the Public Services. By C. li. B. Keetley, 
F.R.C.S. Second Edition, revised and enlarged with the 
assistance of Robert Wharry, M.D. Price 3b. 6d. 

Medical Profession. The Medical Profession : being the Essay to 
which was awarded the First Carmichael Prize of .£200 by the 
Council of the Royal College of Sui^eons, Ireland, 1879. By 
Walter Rivington, B.A., M.B., F.R.C.S. Price 6a. 

Medical Profession- The Medical Profession in 1879 : being the 
Essay to which was awarded the Second Carmichael Prize of 
£100. By Thomas Laffan, L.K.Q.C.P.L, M.R.C.S. Ed., 
Physician to the Cashel Union and Fever Hospitals. Price 4a. 



22 



Bwlli^re, luidall, and Cox's Books. 



WtlHlfl' P rfffffTfl'n Medical Hen tad Hautcnof OteKiaeteendi 
OntaDj. Bj a PbjBeiui. Thiid Tboaaaad, price 3m. 



■ediol Xefimn. ALeUertotheBul^Hon. A.J.]iiuidelk,M:P. 
Bj Jake; Gbkt Guivkb, ItD. ^in. P^im II 

Medical Sefoam. The G«o«nl Uedica] Council : Whom it Bepre- 
mdU, and Uow it Bbonld be Becoostmcted. Bj Abchibai.D 
Uaiciltox Jacxib, M.D. Dab^ F.KCS^ Sn^eon-Ocnlist to His 
Excellency the Lord lieutenant. Professor of Ophtbalmie Sur- 
gery in the Koyal CoU^ of Snrgeons, Ireland. Price la. 

Ifwiiffillft Aids to Medicine. Part L — General Diseases — the 

Lungs, Heart, and Liver. By C- E. Armaxd Semple, B. A-, M.B. 

Cantab., M.R.C.P. Lond. Second thousand, price 2s. 6d. and 2s, 
Part II. — The Urine, Kidneys, Pancreas, Spleen, Stemach, Peri- 

tonenm. Throaty and CEsopha^s. Third Thousand, price 2s. fid. 

and 2s. 
Fart IIL — Diseases of the Brain, Nervous System, and Spinal 

Cord. Third thousand, price 2s. 6d. and 2b. 
Part IV. — Fevers, Skin Diseases, and Intestinal Worms, Price 

Is. paper, Is. 6i cloth wrapper. 
Hedicine. Handbook of the Practice of Aledicise. By H. AOBREY 

Hu.SBA.\D, M.B., F.R.C..S.K Third Edition. Price 7s. 6d. 
Medicine- A Chronology of Medicine from the Earliest TimeK. 

By J. MoRCAN EICHA.RDS. Price 10B,,6d. 
Medico-Military Services. Our SerricsE under the Crown. A 

IliBtorical Sketch of the Army Medical Staff. By Surgeon- 
Major Albert A. Gore, M.D. Price Cs. 
Meteorology. The Moon and the Weather: the probability of 

Lunar Influence reconsidered. Showing how storms and 

depressions may be predicted. By Waltes J. Browne (St. 

Petersburg). Price 3s. 
Hicrobes, in Ferraentatioc. Putrefaction, and Disease. By Chas. 

Cameron, M.D., LL.D., M.P. Price Is. 

PmfeaortyailitU, F.II.IJ.. vniti'H:—"HatthB« Arnold LliusslI could nut find fault with its 
luoUUty. wlilfc lureKKrd" kiiowlodgB and gnuipof Ihoeubjeot I hnvo ttutjIt mot Its equil." 

Microscope. A Compendium of Microscopical Technology, the use 
of the Microscope in the preparation of iliatolo^cal and Patho- 
logical Specimens. By Carl Seiler, M.D., Director of the 
Biological Lectures of the Academy of Natural Sciences, Phila- 
delphia. Illustrated. Price 5a. 



I 

I 



Baillifere, Tindall, and Cox's Books. 



23 



Microscopical Science- The Journal of Microscopy and Natural 
Science. Edited for the Postal Microaeopictd Society by 
AURED Allen, Quarterly with plates. Price Is. 6d. 

MicroscopicSil Science. Studies in Microscopical Science for the 
use of the Medical Profession, Students, and others interested 
in the progress of the Natural Sciences. Edited by Arthur C. 
Cole, F.R.M.S., assisted by eminent Micioscopists. Vol. I. 
containing 53 plates in chromo-lithography. (!loth, price 27s. 6d. 
Half-morocco, 31s. 6d. Vol. II., half-morocco, 31a. 6d. Vol 
IIL in course of publication. 

Midwifery. The Principles and Practice of Midwifery and DiseasBs 
of Women. By Alexander Milne, M.D., Vice-president of 
the Obstetrical Society of Edinburgh. Second edition, with 
Dumeroua illustrations, price I2s. 6d. 

Mind. The Training of the Mind for the Study of Medicine. A 
Lecture delivered at St. George's Hospital. By Robert Brude- 
NKLL Carter, F.RC.S., Surgeon to the Hospital Price 1b 

"No una can read It withnut Imraing Bad profiting mucli."—SiiKf(nU' Jovnial, 

Mineral Watars. The Mineral Waters of Europe. 

Analytical Guide to all the Bottled Waters, and their Medicinal 
and Therapeutic Values. By PR0FE3SOR TiCKBOKNE, LL.D., 
F.C.S., President of the Pharmaceutical Society of Ireland, and 
M. Prosser James, M.R.C.P., Lond., Lecturer on Therapeutics, 
London Hospital. Price Ss. 6d. 

"Such a booku^ this la Bimply Iti valuable." — Tfif World. 

"T^iiH admirable and candao haad.book moetti a Teiy preaaiDg want.^' — -AtbenttutiL 

Morals- A Physician's Sermon to Young Men. By William 
Pratt, M.A., M.D., etc. Sixth thousand, price la. cloth. 

"The delicalB topi^ ia handled -niaclj, judiclonslj-, ind n:llglouair, aa well aa very plainly. ' 

Morals. Revelations of Quacks and Quackery. A Directory of the 
London and Provincial Quack Doctors ; with Facts and Cases 
in Illustration of their Nefarious Practices. By " Deteotor." 
Twenty-eighth thousand, price Is. 6d, 

Naval Hy^eiie. A Manual of Naval Hygiene, for the Preserva- 
tion of Health, and the Prevention of Disease on Board Ship. 
By J. Wilson, M.D. Second Edition. Price 10s. 6d. 

" N'tN ahip ahould lea^B pott wlthnut this IrtBtnLetive manual; yachtsmen will alao find it a 
mnfit reikdablo and uflcfiil UDUipanimi."— 7^ Jf'uld- 

ITephritis. The Microscopic Anatomy of Interstitial Nephritis, 
The Gold Medal Thesis in the University of Edinburgh. By 
Bryan C. Waller, M.D., F.RC.S. Edin. Price 4s. 6d. 



I 



24 Baillifere, Tindall, and Cox's Books. 

Nenral^a. Its Nature, Causes, and Curative Treatment. By Thos. 
Stketch Dowse, M.D., F.R.C.P. Edin., formerly Medical Super- 
intendent of the Central London Sick Asylum. Price 7a. 6d. 

Nose. Laryngoscopy and Rhinoacopj' in Diseasea of the Nose and 
Throat. By Prosser Jasies, M.D., Physician t« the Hospital 
for Diseases 'of the Throat. Fourth Edition. Price 63, 6d. 
With coloured plates. 

Nursing. How to Feed an Infant. With an Appendix on the 
Common AilmentB of Infancy, with their Hygienic and Curative 
Treatment. By Benson Baker, M.D. Price la. 6d. 

" FopuliLr!; writteDt aucI uiulble In tlio lilgheat degree, its wlileaprmd iroTuaal vould bcdl> 
to briag about a more ratlanal Aystem of brinsfnff ap InfBr"- " '■-- — 
'• Bmed upou tho wldB and practical 1 









Nursing'. How to bring up Children by Hand. By J. FOSTER 
Palmer, L.RC.P. Price 6d, 

Nursing. Practical Guide for the Young Mother. From the French 
of Dr. Brochard, Direct or- General of Nurseries and Creches, 
with Notes and Hints by a London Physician. Price 3a. 

Obstetrics. Aids to Obstetrics. By Samuel Nall, MB. Cantab., 

M.E.C.P, Lend., First Class Hoiioura Nat Sci. Cambridge, 
Casualty Physician, and Resident Obstetric Assistant, St. Bar- 
tholomew's Hospital. Price 2s. 6d. cloth, 2s, paper wrapper. 

Obstetrics. Hints in the Obstetrical Procedure. By W. B. 
Atkinson, A.M., M.D. Obstetric Physician to the Howard 
Hospital, Philadelphia, Second edition. Price is, 

ObstetriCEl. Obstetrics and Diseases of Women. By Robert 
Barnes, M.D., F,R.C.P. {see chapters in Gant's Surgery). 

Obstetrics. On Fibrous Tumours of the Womb : Points connected 
with their Pathology, Diagnosis and Treatment. By C. H. 
F. EouTH, M.D., M,R.C.P. Loud., Senior Physician to the 
Samaritan Hospital for Women. Price 3s. 6d, 

Old Age, The Diseases of Sedentary and Advanced Life. By J. 
MiLNER FoTUEKGiLL, M.D., M.K.C.P. Lond., Physician to the 
City of London HoBpital_, for Dieeases of the Cheat. (7n the 
Press.) 

Osteology. Osteology for Students, with Atlas of Plates. By 
Arthur Trbhern Norton, F.R.C.S., Surgeon to, and Lecturer 
on Surgery at, St Mary's Hospital Atlas and Text in one 
volume, 7s. 6d. ; in two volumes, 8s. 6d. 

'^ThBbandiAt and mcul^ oompletB hand-book of Oflteolugf."— TVie Lajictl. 



I 

I 



Baillifere, Tindall, and Cox's Books. 



25 



Orarian Disease. The Pathology and Treatment of DiseaBca of 
the Ovaries (Haatings Prize Essay). By Lawson Tait, 
F.R.C.S., Surgeon to the Hospital for Women, Birmingham. 
Fourth edition, revised and enlarged. Price lOa. 6d. 

Overwork. Overwork and Premature Mental Decay : its Treatment. 
By C. H. F. KoiiTH, M.D., M.R.C.P. Lond. Price 2a. 6d. 

Pathology Examination Cards. Arranged as questions and 
answers for self-examination. By A, T. Schofield, M.D., 
M.E.C.S. Complete in two sets of cards, price 9d. nett per set. 

Mr. JonnHifln HutrLinnon, F.R.C.B., wriWs ; " 11 Is i.u InvalTinblo moans of Bolt tuiUon." 

Pharmacy. Latin Grammar of Pharmacy, for the use of Students, 
with an Essay on Latin Prescriptions. By Joseph Ince, 
A.K.C.L., formerly Examiner and Member of Council, Phar- 
maceutical Society. Third Edition with appendix. Price 4s. 

Pharmacy. Aids to Pharmacy. By C. E. Armand Simple, B.A. 
M.B., Cantab., M.E.C.P., Lond., Examiner in Arts at the 
Apothecaries' Hall, cloth, price 2s. 6d. ; paper wrapper 26. 

Pharmacy. A Treatise on Pharmacy. A Test-book for Students, 
and a Guide for the Physician and Pharmacist. By Edwakd 
Pakrish. Fifth edition, revised by T. S. Wiegand, F.C.S. 
With 300 illustrations, half-bound morocco, price 30b. 

^* Tban la uuthlng to eqiuU FarriBh'A PlmnD;tcy in tliU on any other LiuguAjfo." — FAai'mn- 

Pharmaty. Notes on the Pharmacoposial Preparations {being 
Part II. of a " Text-book of Materia Medica and Pharmacy "). 
By Drs. Handsel Griffiths and G. F. Duffey. Price 3s. 6d. 

Phimosia The Causes, Symptoms, and Treatment of Phimosis and 
Paraphimosis, with a description of the ancient rite of circum- 
cision. By L. H. Ormsby, M.D., F.E.C.S.I., Lecturer on 
Clinical and Operative Surgery, surgeon to the Children's 
Hospital, Dublin. Price Is. 

Physiology. A Manual of Physiology. By E. D. Mapother, 
M.D., Professor of Physiology; formerly President Eoya] College 
of Surgeons, Dublin. Third edition, edited by T. F. Knott, 
Demonstrator of Anatomy, Eoyal Coll. of Surgeons. Price 149, 



Physiology. Aids to Physiology. By B. Thompson Lowne 
F.R.C.S., Arris and Gale Lecturer, and Examiner in Physiology 
Eoyal College of Surgeons of England. Fourth thousand, illua 
trated. In two parts 2s. each, or in one vol., cloth, 4s. 6d 



26 



Bailli^re, Tindall, and Cox's Books 



Physiology. The Physiologist in the Household. By J. Milner 
FOTHERGILL, M.D., M.R.C.P. Part L— Adoleacence. Price Is, 

Physiological Ohemiatry- Aids to Phyaiologioal Chemistry. By 
J. L. TuiTDicuuM, M,D., r.K.C.P., Lond. Formerly Lectiirec 
on Physiological Chemistry, St Thomas's Hospital Cloth, 
price 23. 6d. Paper wrapper, 28. 

Physiological Factor in Diagnosis. By J. Milner Fothergill, 
M.D., M.R.C.P., Lond., Physician to the City of London 
Hospital for Diseases of the Chest. Second edition. Price 7b. 6d. 

Physiological Laboratory. Manual for the Physiologicai Labora- 
tory. By ViNCUNT Habris, M.D., M.R-C.P., Examiner in 
Physiologj', Eoyal Collego of Physicians of London, and D'Ahcy 
Power, M.B. Oson., Curator of Museum, St. Bartholomew's 
Hospital Third edition. Price 5b. 

"Thts muiiiiillH already well nnd InTDUUbly known, uid the new sditiou soolaiu nuiDf 

" Tbe fine edldon vm one ot sonsldeiable merit, but tha UliutnitloaB in Ok pment volume 
huve gToatlr iacnuuiid iU vnlUB."— Jtrilii/i MuIkoI /oanwl. 

"The lnctru<?MonB ura pnictlal, clear and jireciae, and the UDDiuit ot grmmd gorered la 
aarprislTig hy \aTge."—8iiisffoio Xedieal Jott'^ttaL 

Population. On the Evils, Moral and Physical, likely to follow, 
if practices, intended to act as checks to population, be not 
strongly discouraged and condemned. By C. tL F. KoOTH, M.D., 
F.R.C.P. Second thousand, price Is. 

Posology. Fosological Tables : a Classified Chart, showing at a 
glance the Dose of every Officinal Substance and Preparation. 
By Handsel Griffiths, Ph.D., L.E.C.P. Fifth edition, 
revised by Peter Wyatt Squire, F.C.S., price la. ; or mounted 
on linen, rollers, and varnished, 3s. 6d. 

Posological and Therapeutic Tables, containing the Doses, Ac- 
tions, and Uses of the Medicines of tile British Pharmacopoeia. 
By Alexander Henry, M.B. Second edition, cloth, 28. 

Prescriptions. The Student's Pocket Prescriber. By H. AuBRET 
HuriiiANJ), M.B., F.R.C.S.E. Price Is., cloth. 

PnbliC Health- The Practical Guide to the Public Health Acts 
and Correlated Acts, for the use of Medical Officers of Health 
and Inspectors of Nuisances. By Thos. Whitkside Hime, 
B.A., MB., Medical Officer of Health for the Borough of 
Bradford, lately Medical Officer of Health for the Borough of 
Sheffield. Bound leather, gilt edges, price Ss. 



I 



BaiUifere, Tindall, and Cox's Books. 27 



Put)Iic Health. Aids to Public Health. By J. L. THtiDiciitia, 
M.D., F.K.C.P., Lond. Price Is. 6d. cloth ; la. paper wrapper. 

Plant Analysis. Quantitative and Qualitative. By G. Draoen- 
DORFF, Professor ofCbemistry aod Piiarmacy in the University 
of Dorpat. Translated by Hy. G. Greenish, A.I.C. Ts. 6d. 

Salt. History of Salt, with Observations on its Medicinal and 
Dietetic Properties. By Evan Marlett Boddy, F.R.C.S,, 
F.S.S., L.R.C.P. Price 3s. 6d. 

Sanitary Law. A Digest of the Sanitary Acts. By H, Aubrey 
Husband, B.Sc., F.E-CS., Edia. Price 33. 6d. 

Sewagfe. The Sewage Question : Reports upon the Principal 
Sewage Farms and Works of the Kingdom, with lHotea and 
Chemical Analyses. By the late Dr. Letheby. Price is. fid. 

"Those Beporta will diaHlpato obKiuity, aud, by pljiciu^ the aubjoct in a proper llgbt, vrill 
anablB loual Huthoritlea, and uthera interested In the matter, to perceive the actual truthe of 
the question, aud to apply thompnictlciUlj." 

Skeleton. Movable Atlas of the Skeleton and its Articulations, 
showing the Bones aud Ligamenta of the Humaa Body aad 
Limbs. By Prof. Witkowski. Price 7s. 6d. (See Anatomy.) 

Skin. Some Diseases of the Skin produced by derangements 
By T, Stretch Dowse, M.D., 



in. Lectures on Ring-worm and other Diseases of the Skin, due 
to Vegetoid Parasites. By Jas. Startin, M.KC.S. Price Is. 

iph. The Sphygmograph : its History, and use as an 
ignosis. By R. E. Dudgeon, M.D. Price 2s. 6d. 

Diseases of the Spinal Cord. By Byrom Bramwell, 
M.D., F.R.C.P. Ed., Pathologist to the Royal Infirmary Edin- 
burgh. Second Edition. Price 153. 

Snrgery. The Science and Practice of Surgery, being a Complete 
Text-book. By Fredekick J. G.4NT, F.R.C.S., Senior Sur- 
geon to the Royal Free Hospital. Second edition, with 
nearly 1000 engravings, new and original, in 2 vols., price 
31s. 6d. 
"With special chapters by 

Wm. Ailams, F.R.C.S.. Daformitiea. I Hy. Power, F.R.C.S,, Ophthalmic Siagery. 

Boht. BaniBa,M.D.,F.R.C.P.,OliBtatrieB. Laidlaw Purves, M.D. . Aural BnTgory. 
MoreU Mackenzie, M.D., The Throat. C. S. Tomes, F,H.S„ Dantal SurgaiT. 

F.A.Malionied,U.D..TheSph;gaiograph. | Sir Erasmus Wilson, FJt.S., The Skin. 

" Do«a credit tc the autbor'H thmitUKh aur^naL kuowlcde^." — British Stedical Jonmal. 

" Will bocomo one at the moet popular Bur^cal Text-bDoks in the £Dglieh langna^,^' — 

"A VBry complete aud tnintworthy giiidc topnicticu," — JUsdical Tima. 



28 Baillifere, Tindall, and Cox's Books. 



Surgery, Aids to Surgery. By George Browx, M.E.C.8, 
Purts I. and II., price is. Gd. and la. each. 

Surgery. The Text-book of Operative Surgery, From the French 
of ProfoHsors Claude Bernard and Huette. With 8S plates. 
Text edited and rewritten, by ARTHUR Trehern NurtoN, 
F.Ii.C.S., Surgeon to, and Lecturer on Surgery at, St. Mary's 
Hospital. New edition in the Press. 

"Of thfl hljtJjDat morlt oaaiTiilda toopeiatiTDHur^far;."— SfvJfnU' Jtmraal, 

Surgery. Abstracts of Surgical Principles for Students. By 
TuoH. Annandale, F.R.C.S., F.R.S., Surgeon to, and Lecturer 
on Surgery at, the Royal Infirmary, Edinburgh. Price 7s. 6il. 

Surg^ery. A Manual of the Operations of Surgery, for the use of 
Senior Students, etc By Joseph Bell, F.E,C.S., Lecturer on 
Surgery, Koyal Infirmary, Edinburgh. Third edition, price 6s. 

Surgery. Annals of Surgery. A monthly Review of Surgical 
Science and Practice, published simultaneously in New York 
and London. Edited by L. S. PlLCHEB, M.D., of Brooklyn, and 
C. B. Keetley, F.E.aS., of London. Price Ss. monthly, or 21s. 
per annum post free. 

Surgical Anatomy. The Student'sHandbook of Surgical Anatomy. 
By John McLaciilam, M.B. Price 2s. 

Surgical Treatment Notes on Surgical Treatment and Minor 
Operations. Designed especially for House Surgeons and 
Students. By T. F. HopGooD, L.E,C,P., M.K.C.S. Surgeon to 
the Sunderland Infirmary. Price 2s. 6d. 

Sypllilis. The Nature and Treatment of Syphilis and the other so- 
called Contagious Diseases. By C. R, Dry8DALE,M.D., M.E.O.P., 
Lond., F.R.C.S. Eng., Senior Physician to the Metropolitan 
Free Hospital. Fourth edition. Price is. 6d. 

Teeth. Dental Surgery. By ClUS. S. ToMES, M.A, Oxon, F.R.S. 

(See chapters in Gaut'a " Surgery.") 

Teeth. The Dental Student's Xote-Book. By OaklET Coles, 
L.D.S. Second thousand, price 2s. 6d. 

Theories of Disease. The Germ Theories of Infections Diseases. 
By John Duysdale, M.D., F.R.M.S., President of the Liverpool 

Microscopical Society. Price la. 

Theories of Disease. A Parasitic or Germ Theory of Disease : 
the Skin, Eye, and other affections. By Jauez Hogg, M.R.O.S,, 
Consulting Surgeon to the Royal Westminster Ophthalmic 
Hospital. Second edition, price 2s, 6d. 



Baillifere, Tindall, and Cox's Books. 29 

Theories of Life- Life and the Equivalence of Force. By John 
Drysdale, M.D., F.E.M.S., President of the Liverpool Micro- 
scopical Society. 

Part I. Historical Notice of the Discovery of the Law of 
Equivalence of Toroe. Price Is. 

Part II. Nature of Force and Life : containing the Harmony 
of Fletcher and Eeale. Price Is. 6d. 

Theories of Life. How to Prolong Life J Showing the Diet and 
Agents best adapted for a leagtheneil prolongation of existence. 
By C. W. De Lacy Evans, M.E.C.S. Second edition. Price Ss. 

"A good account ot tho Bomfilic chomjes which ncciir with Urn ndvinco of age."— 
" This IB a. >Hry;fiigaiiioiia and interestiDg book."— Cft™ij£ and Oruflcisl- 

Tbeories of Life. Tlie Protoplasmic Theory of Life. Containing 
the Latest Researches on the subject. By JOHN Drysdalk, 
M.D., r.B.M.S. Price 5s. 

Therapeutics. Modem Medical Therapeutics. A compendium 
of recent Formula and Specific Therapeutical directions, from 
the practice of eminent Contemporary Physicians, English, 
AmericaD, and Foreign. Edited by G. H. Napheys, A.M., M.D. 
Eighth edition, price 18s, 

any pmcfitione 
uie JSedUai Joamat. 

Therapeutics. Modem Surgical Therapeutics. From the Practice 
of^ eminent contemporary Physicians and Surgeons, Euglish 
American, and Foreign. Edited by G, H. Napueys, A.M., 
M.p. Seventh edition, price 18s. 

Therapeutics. The Principles and Methods of Therapeutics, 

Translated from the French of Adolphe GuBLBit, M.D., 

Professor of Therapeutics in the Paris Faculty of Medicine, 
half-calf, price 18s. 

Therapeutics. The Therapeutics of the Respiratory Passages. By 
PROSHER James, M.D., Lecturer on Materia Medica and Thera- 

Eentics at the London Hospital, Physician to the Hospital for 
liseases of the Throat. Price 10s. 6d. 

"nr. Froesor Jamea liM produosd a acliolarly treatise."— IfsuJ Tork llrdiaiHttcord. 

Therapeutics. Aids to Rational Therapeutics, for the guidance of 
Practitioners and Senior Students, By J. Milner FotheRgill, 
MD. Price 2s., paper wrapper; 2s. 6d., cloth. 



m 



30 Baillifere, Tindall, and Cox's Books. 



Throat- Movable Atlas of the Throat, and the MechaniBin of Voice> 
Speech, and Taste. By Prof. Witkowski. {See Anatomy.) 

Throat- Diseases of the Throat. By MoBELL Mackenzie, M.D. 
(See chapters in Gant's "Surgery.") 

Throat- The Throat and its Diaeases. A Fractii:al Guide to Diag- 
nosis and Treatment. With 100 typical illustrations tn chromo- 
lithoaraphy and 50 wood engravings. By Lennox Browne, 
F.R.C.S. Edit!., Senior Surgeon to the Central London Throat 
and Ear Hospital. Second edition, (/w PieparatioTi..) 

Throat. Affections of the Throat and Larynx. By Artiidr 
Trehern Norton, F.R.C.S., Surgeon to St. Mary's Hospital. 
Second edition, illustrated, price 6s. 

'■ fihort, dimple, ukI tboroughly praotJcttl InBtnictloo."— JJ(ni«a( Tltna. 

Throat Laryngoscopy and Rhinoscopy r in the Diagnosis and 
Treatment of Diseasee of the Throat and Nose. Illustrated 
with hand-coloured plates and woodcuts. By Prossee James, 
M.D., M.R.C.P-, Physician to the Hospital for Diseases of the 
Throat. Fourth Edition, Price 6a, 6d. 

TransfnaioiL- On Transfusion of Blood and Saline Fluids. By 
Charles Egerton Jennings, L.R,C.P., London, F.R.C.S., 
formerly House Physician and Resident Accoucheur at the 
London Hospital. Second edition, with Illustrations and Pre- 
face, by Sir Spencer Wells, Bart, crown Svo, 3s. 6d. 

Traneactions of Societies- Transactions of the Academy of 
Medicine in Ireland. Edited by William Thomson, M.A, 
F-R.C.S., med. Svo. cloth. 414 pp., with numerous plates and 
woodcuts. Vole. I, and II. Price 148. each. 

Urine. The Urine; a Guide to its Practical Examination. By 
J. Tyson, M.D., Professor of Morbid Anatomy in the University, 
and President of the Pathological Society of Philadelphia. 
Fourth edition, with numerous illustrations, price 7b. 6d. 

" Wo thtnlt it tho moat pnu:tlmUy iweful guide wo Ieto on tho iubject-"— JfHticn) Rerord. 

Urinary Diseases. Diseaaea of the Bladder, Prostate Gland, and 
Urethra. By F. J. Gant, F.E.C.S-, Senior Sui^eon to the Royal 
Free Hospital. Fifth edition revised and enlarged, with nu- 
merous illustrations, price 12s. 6d. 

Vichy. Vichy and its Therapeutical Resources, By PROSSER Jauss, 
M.D., M.R.C.P., Lond, ; Lecturer on Materia Medica and 
Therapeu'-ics at the London Hospital ; Physician to the Hospital 
fur Diseases of the Throat, cloth, price 2s, 6d, 

Voice. Artistic Voice in Speech and Song. Dedicated by special 
permission to Mr. Sims Reeves, Mr. Santley and Mr, Maas. 
By Charles Lunn. Price Is. 



Baillifere, Tindall, and Cox'a Books. 



31 



Voice. The Philosophy of Voice. Showing the right and wrong 
Action of the Breath and Vocal Cords in Speech and Song, 
By Charles Lunn. Fourth Edition. Price Is, 6d, 

ToiCfl. The Voice Musically and Medically Considered. By C, 
Armand Sebiple, MB., Cantab., M.R,C.P., Lond., Physician 
to the Boyal Society of Musicians, Price Is, 

Voice. Clinical Lectures on Hoarseness and Loss of Voice. By 
A. Trehern Norton, F.R.C.S., Surfjeon in charge of the 
Throat Department at St. Mary's Hospital. Price Is. 

War. A Romance of War ; or, How the Cash Goes in Campaigning, 
Compiled from the Evidence before the Committee of tlie House 
of Commons on the recent Egyptian Campaign. By Charles 
Cameron, LL.D., M.P. Second Thousand. Price Is. 

Whooping-CouglL Its Pathology and Treatment, Being the Prize 
Essay to which the Fothergillian Gold Medal of the Medical 
Society of London was awarded in 1S82, ByTaos. M. Dolak, 
M.D., F,K.C.S,E. Price 3s. 6d. 

Wiesen. As a Winter Health Resort in Early Phthisis, with in- 
structions on diet, cJothing, etc., in the Swiss Alps, during wicter. 
By A. T. Tucker Wise, M.D., cloth, with maps, price 3s. 6d, 

Zoology. Syllabus of Vertebrate Morphology, A few of the more 
important facts regarding the Zoology of the Vertebrata. By 
J, K West, Demonstrator Royal College of Surgeons, Edin. 
Price la. 6d; 

Zoology and Comparative Anatomy, Aids to. By Majok 
Greenwood, M.E.C.S., L.E.C.P., Honours in Zoology, Uni- 
versity, of London. Price 2s, 6d,, cloth, and 2s. paper. 



32 Baillifere, Tindall, and Cox's Books. 



THE STUDENTS' AIDS SERIES. 

r all the Matriculation Examinations, University and Medical 
College Exatni nations, including the Classics. 



Specially designed to assist Students in committing to memory and 
grouping the subjects upon whiah they are to ba examined. 

Aids to Analyaia of Food and Drugs. By H. Axtbrey 
Husband, MB., F.B.C.S., Lecturer on Public Health in the 
Medical School, Edinburgh. Price Is. 6d, Is. 

Aids to AnatoBUr. By George Brown, M.R.C.S., Gold Medal- 
ist, Charing Cross Hospital Eighth Thousand. Price Is, 6d. 
cloth ; Is. paper wrapper. 

"The little book is wail done."— I.mM(. 

Aids to Botany. By C. K Armanc Semple, B.A., M.B. Caatab,, 
M.R.C.P., Lond., late Senior Examiner in Arts at Apothecaries' 
Hall. Third Thousand. Price 2s. fid cloth ; ^s. paper wrapper. 
Aids to Chemistry. By the same Author. 

Part I. — Inorganic : Non-Metallic Substances. Fifth thou- 
sand, price Is. 6d. and Is. 

Part IL— Inorganic : The Metala. 2s. 6d., 2s. 

Part III. — Organic. Price, cloth 28, 6d.; paper2s. 

Part IV.— Tablets of Chemical Analysis. Is. 6d., Is. 

Aids to Diagnosis. Parti. — SemeiologicaL By J. MilnerFother- 

GiLL, MD., M.R.C.P. Lond. Price la. 6d. cloth; ]s. paper. 

Part IL— Physical By J. C. Thorowgood, M.D., F.R.C.P. 
Lond. Price Is. 6d. cloth; la. paper wrapper. 

Part III.— What to Ast. By J. Milner Pother gill, M.D., 
M.R,C.P. Lond. Price Is. 6d. cloth; Is. paper. 

" A rnino ol valuabk informatloa."— ffllluiurj* ittdlml Jmrnal. 

Aids to EsaminationS- Being Questions and Answers on Materia 
Medica, Medicine, Midwifery, Pathology, etc By W. Dottglas 
Hemming, F.R.C.S., and H. Aubrey Husband, M.B., F,R.C,S. 
Third thoixsand. Price la. Gd. cloth; and Is. jiaper. 

Aids to Forensic Medicine and Toxicology. By W. D. Hem- 
ming, F.R.C.S.K, and H. Aubrky Husband, M.B., F.R.C.S.E. 
Third Thousand. Price Is. Cd. and Is. 

" Wa liaTO uo liastUtJon in roconuDondiug Mr. Hommiag's book-"— ijiiint. 

Aids to Gynaecology. By Alfred Gubb, M,E.C.S., L.RC.P., 
Obstetnc AssistJint and Gold Medallist, Westminster Hospital. 
Cloth, price Is. 6d. ; paper wrapper. Is. 



Bailli^re, Tindall, and Cox's Books. 33 



Part I.— The Non-Metallic and Metallic Elements, Alcoholic 
and Ethereal Preparations. Fourth Thousand shortly. 

Part II. — Vegetable and Animal Substances, 2a. 6d. and 2s. 

Part III. — Tablets of Materia Medica. Price Is. 6d. and Is. 
Aids to Modicine. By the same Author. 

Part I. — General Diseases. Lungs, Heart, and Liver. Third 
Thousand. Price 23. 6d, and 28, 

Part II.- — The TJrine, Kidneys, etc. New edition 2s. 6d., 2a. 

Part III. — Diseases of the Brain and Nervous System. 
Price 2s, 6d. and 2s. New edition. 

Part IV.— The Fevers, Skin Diseases, &c. Price la. Cd. and la. 

Aids to ObstetxicB. By Samuel Nall, B,A., M,B., Cantab., 

M.K.C.P., Lond,, late House Physician and Resident Obstetric 

Assistant, St. Bartholomew's Hospital. Price 2s. 6d. cloth, 23. 

paper. 

Aids to Pharmacy, By C.E Armand Semple, B.A.,M.B., Cantab., 

M.E.C.P,, London. Cloth, price 2s. 6d. ; paper wrapper, 2s. 
Aids to Physiology. By B. Thompson Lowne, r.Ii.C.S., Ex- 
aminer in Physiology, Koyal College of Surgeons. Fourth thou- 
sand. In two parts price 2s. each, or in one vol., cloth, 43. 6d. 

" Certainly onu ot tha beat uf tho now popular Aida Serise."— S(U(i<-«!(' Jonnrnl. 

Aids to Practical Physiology. By J. Brindley James, M.R.CS. 
Price Is. 6d,, cloth ; Is., paper. 

Aids to Physiological Chemistry. By J. L. Thudichum, M.D., 
F.E.C.P., Lond., formei'ly Lecturer on Physiological Chemistrj', 
St. Thomas's Hospital, Price 2s, 6d and 2s, 

Aids to Psychological Medicine. By L. S. Forbes Winslow, 
M,B,, D.C.L. Oxon. Price Is. 6d. and Is. 

Aids to Public Health. By J. L. Thudichum, M.D., F.E.C.P., 

Lond. Price Is. 6d. cloth, Is. paper. 
Aids to Surgery. Part I, — By George Brown, M.Ii.C.S. Price 

Is. 6d. and Is. Part II. Is, 6d. and Is. 
Aids to Rational Therapeutics. By J. Milner Fothergill, 

M.D., M.R.C.P. Load. Double Part. Price 2s. 6d. and 26. 

Eeplies to Questions in Therapeutics. By Brindley James, 
M.R.CS. Price Is, 6d, cloth. Is. paper wrappers. 

Aids to Zoology. By Major Greekwood, M,R,C,S,, L.E.C.P., 
Honours in Zoology, University of London. Price 2s. 6d., and 2s. 



34 Baillifere, Tindall, and Cox's Books. 



CATALOGUE OF WORKS 

IN 

VETEEINARY MEDICKE AND SURGERY. 



Amateur. Horses : their Rational Treatment and tho Causes of 
thoir Premature Decay. By Amateur. Price 5b. 

An Abridgment of the above. By the same Author. Price 

la. 

Beacock. Prize Essay on the Breeding, Rearing, and Fattening of 
Cuttle and Shetp, and proper treatment of Cows at time of 
Calving. By JosisrH Beacock. Price 3d. I 

Bomess — Mavor. Tlie Specific Action of Drugs, an Index to ' 
their Therapeutic Value. By ALEXANDER G. BuBNESS and F. 
Mavor, President of the Central London Veterinary Society. 
Price 10s. Gd. 

Chauveaa — Fleming. The Comparative Anatomy of the Domes- 
ticated Animals. By A, Chauveau, Professor at the Lyons 
Veterinary ScKool, and Georgb Fleming, M.R.0.V,S. i50 en- 
gravings. Price 31s. 6d. 

Tlie Original Work in French. Price 20a. 

Fearnley. A Text-Book on the Examination of Horses as to 

Soundness. A cciursa of Lectures enlarged, delivered at the 
Eoyal Veterinary College, Edinburgh. By Professor FBABNi-By, 
with an Appendix on the Law of Horses and Warranty. Price 
78. 6d. 

Lessons in Horses Judging, Price 4a. 

' The Simple Ailments of Horses their Nature and Treatment. 

Price 6s. 

Fleming. A Text-Book of Veterinary Obstetrics, including the 
diseases and accidents incidental to pregnancy, parturition and 
early age in the Domesticated Animals. By George Fleuinq, 
LL.D., F.IM' V.S,. VM U.S., President of the Eoyal C< " 
Veterimiii '■■ ■ ■ I ■Im ijial of the Army Veterinary 

ment. I'm i ■ '''I. Cloth, price 30s. 



II 



t atouk breeding at 



Baillifere, Tindall, and Cox's Books. 



35 



r 



Fleming. A Text-Book of Operative Veterinary Surgery, Parti, 

price lOs. 6il. 
— — — The Contagious DiseaBes of Animals : their influence on the 

■wealth and health of the nation. Read before the Society of 

Arts. Price 6d. 

Animal Plagues; their History from the Earliest Times, 

Nature, and Prevcntioa Vol. I., price 15a 

Vol. II., from A.D. 1800 to 1844. Price 12a. 

Tuberculosis from a Sanitary and Pathological point of Tiew. 

Price Is. 

Human and Animal Variolie. A Study of Comparative 

Pathology. Price Is. 

Practical Horse Shoeing. With 37 illustrations. Third 

edition, enlarged, 8vo., sewed, 2s. 

A Manual of Veterinary Sanitary Science and Police. 2 vols. 

With 33 illuatratioiis. Demy 8vo. Price 36a. 

The Influence of Heredity and Contagion on the Propagation 

of Tuberculosis. By G-. Fleming, r.RC.V.S., Here A. 
Lydtin, and M. Van Hertsen. Price 3s, 6d. 

Gresawell- A Manual of the Theory and Practice of Equine Medicine. 
By .T. Beodie Gresswbll, M,E.C,V.S., and Albert Gress- 
WELL, M.RC,S, Eng. Price lOs. 6d, 

Heatley, Practical Veterinary Eemedies, A useful Handbook 
on Medicine, By G. S, Heatley, M.Ii-C.V.S, Price 3s. 6d. 

Hill. The Management and Diseases of the Dog. Copiously illus- 
trated. By J. WOODROFFE Hill, F,K,C,V,S, Second edition, 
10s. 6d, 

" Contjiias roQct VfllimWe information."- Wf /^W. 
"Ad excelloDt aud comiJeto nmnuiiL"— IT.; Slaadard. 

Principles and Practice of Bovine Medicine and Surgery. 

Copiously illustrated with woodcuts and Coloured Plates. 
Price 36s, 

Lambert. The Germ Theory of Disease, Concisely and Simply 
Explained.' Illustrated by Diagrams and References to Im- 
portant Diseases of Domestic Animals, etc. By James Lambert, 
RE.C.V.S., Army Veterinary Department, Inspecting Veterinary 
Surgeon for Ireland. Price Is. 

Liantard- Animal Castration. By A. LiadtABD, M.D., 

H.F.K.CVS. Price 7b 6d. 
McBride— Mayer. Anatomical Outlines of the Horse. By J. A. 
McBridf^ M.E.C.V.S., and T. W. Mayer, F.E,C.V.S. With 
plain and coloured illustrations. Cloth 8s, 6d. 



36 Baillifere, Tindall, and Cox's Books. 

Meyrick. Stable Management and the Prevention of Diseases 

amoDg Horses in India. By J. J. Meyrick, F.RC.V.S., 

Principal Army Veterinary Surgeon to H.M. Cavalry in Egypt 

Formerly Assistant Superintendent of Horse Breeding for tbe 

Punjab, Price 3s. 6d. 
Keynolds. The Breeding, Bearing, and Management of Draught 

Horses. By Richard Eevnolds, M,E.C.V.S. Price 3s. Gd, 
Soliertson. A Handbook of the Practice of Equine Medicine. 

By William Robeutson, F.B.C.V.S., Principal and Professor 

of Hippopathology in the Boyal Veterinary College, London. 

Price 25 a. 
Strang^ewayS- Veterinary Anatomy. Second edition. By Prof. 

Vaughan, Lecturer on Anatomy and Zoology at the New 

Veterinary College, Edinburgh. Price 243. 
Tellor. The Diseases ofLive Stock and their most efficient remedies ; 

including Horses, Cattle, Sheep and Swine. By Lloyd V. 

Tellor. Price 10s, 6d. 
Walley. The Four Bovine Scourges: Pleuroneumonia, Foot and 

Mouth Disease, Cattle Plague, and Tubercle ; with an Appendix 

on the Inspection of Animals and Meat By Thos. Walley, 

F.R.aV.S. Price 16b. 
Veterinary Diagrams in Tabular Form- Illustrated with 

coloured and platu Engravings. Size of sheet 28i inches by 22 

inches. Price per set of Five, 12s. ; or mounted on roller and 

varnished, 27s. ; or separately as follows : 

No. 1. — The Externa! Form and Elementary Anatomy of the 

Horse. Price 3s. 6d., or mounted on roller and varnished, 6a. 6d. 
No. 2. — The Age of Domestic Animals. Price 23. 6d., or 

mounted on roller and varnished 5s. 6d, 

No. 3. — The Unsoundnesses and Defects of the Horse. Price 

2s. 6d., or mounted on roller and varnished, 5s. 6d. 
No, 4.— The Shoeing of the Horse, Mule and Ox. Price 

2s. 6d., OT mounted on roller and varnished, 5s. Cd. 

No. 5. — The Elementary Anatomy, Points and Butcher's 

Joints of the Ox. Price 3s. 6d., or mounted on roller and 

varnished, 6s. Cd. 
The Veterinary Journal and Annals of Comparative 

Pathology. Monthly, price la. 6J. Annual Subscription laa. 

pre])aid. 



i 



I 



BAILLIERE, TItJDALL, AND COX'S LIST OF 
STANDARD FRENCH WORKS. 



Abadie.— Trait e des maladies des yeux. 3" ediiion - 
Alavolne.— Traitemenl et Curabilite ile la phtliisie pulmonaire 
Andouard. — Nouveaux elements de Phaimatie 
Armand.— Tmite de Cliniatoloj.'ie gfnlrale da Globe 
Arnould. — Nouveaux fitments d'Hygiene 
Audhoui.— Traite des maladies de I'eslomac 
Axenfeld et Bluchard.— TraitedesNevroses. 2' edition 
Barnes. — Lemons sur les opSralions obst*tricales - 
Barth et Roger.— Traiii pratique d' Auscultation suivi 

d'un precis de percussion 
Barthez et Rlllict. — Maladies des Eo&nts, augment^ etc 

par Sanne. y edition. - ■ vef. I 

Bazin. — Traitement des Maladies chroniquesen general, et des 

aiTEctions de la peau en particulier 

Lemons sur les aflections gen^riques de la pean 2 vals. 

Beaunls et BoochartJ,— Nouveaux elements d'anatomie 
;t d'embtyolc^e. 3' edition 



Ptec 



:t de diss 



Beaunls. — Nouveaux elements de physiologic humiine. 

2" edition - - -3 wis. 

Beclard. — Trait^ ilementaire Ae Phyaiolc^e humaine 

Behier et Hardy. — Traite elementaire de Palhologie 

loteme - - L'ouvrage fonnera S vols. 

Vol. I. Pathologie gcnerale et Sem^iologie - 

Vol. II. Inflammations du tube digestif et de 

I'appareil respiratoire, circulatoire et netvenx 

VoL III. Inflammation de I'appareil genito- 

urinaires dela peau et de I'appareil locumoteur 

Vol. IV., I" partie. Fievre lyphoide, fitvre 

inlermittentes, fievre rdmiltente, fievre jaune 

— Seatlatine, etc., etc. - 

Bennel.— Recherches sur le tr^tement de la Phthisis pulmon- 

aire par I'hreiene les cliraats et la mMecine 
Beraud et Robin.— Manuel de physioiogie de rhomme et 
des principaux vertebres - - 2 vols. 

— — et Velpeau. — Manuel d'anatomie chimrgieale 

generale et topographique 
Berenger-Feraud —Traite de rimmobllisation dlrecte des 
fragments cisseux dans les fractures 

Traite des fractures nonconsolid^esou pseud arthroses 

De la fybue bilieuse mclanurique des pays ehauds, 

coniparee avec la fiivre jaune - - - 

De la fiivre jaune diln bilieuse inflammatoirc aux 

Antilles et dans I'Am^riquc tropicale 

Traite clinique les maladies des Europeens au 

.Senegal - - - - 2 ■ools, 
Bergeret. — Abus des boissons ulenoTiques 
Fraudes dans I'accomplissement des fonc lions gine- 

Bergeron. — Precis de petite chirurgieet de chirurgie d'urgence 



38 Bailliere, Tindali, and Coi^s Standard French Works. 



Bernard (Claude). — Lcfons sur le chaleur animale 

Lemons de physiologic experimentale appliquee 

a la mMecine - - - z-v ' 

Bernard. — Le;ons sat les eGTelsdesaubstajicestoxiqaes ct 
dicamenteuses - - . 

Lejons sur la phyiiolc^e et la palhologie du syslime 

Lejons sur les proprieles physiologiquea el les alter- 

ations pathologiques des Uquides de I'Drganisme 

Legons sur les pioprietes des lissus vivanls 

Inttoduclion £L I'elude dc la medecine experimental i 

La^na snr les anesthcsiqnes ct sur I'asphyxie 

Lejons sur le Diabete et la glyconyenese animale 

Lefons de patholi^e eip^rimentale 

Bernstein. — Les sen', i* edition 

Bert. — Lemons sur la physiologic comparie de la respiration 
Berthier.— Des Nevroses meastruetles, ou la menstnuitioi 

dans ses rapports avec les malailies nerveuses &c. 
Des Nevroses diathesiques, ou les maladies nerveuse 

dans leui^ rapports avec la rhumatisme, la goutte, &i 

Classification et di^nostic des maladies mentales 

Be rton.— Guide et questionnaire de tons les enamens d 

medecine, avec les reponses - 
Bidlot. — Etudes deadiverses espeDcade phthisie pulmonairc f. 

sur le traitement applicable 4 chacnne d'ellts 
Binet.— Du eomage broncho-tracheal et de ses rapports ave 

Binz. — Abrtige de matiere medicale et de iherapeutique 

Birot — Essoi sur les albumlnes pathalogiques 

BlTort. — Observaticos et ftudes sar les causes, la prophylaxi 

et ie traitement de la fievre lyphoide 
Bocqulllon. — -Manuel d'histoire natuielle medicale 
Bolsseau.— Des maladies simuWes et desmoyens delesrecon 

Boivin et Dugeg.— Anatomic pathologiquc de 1' 



m£ll« 



Bossu (A.)— Lois et mysterea des fonctjons di 
consid^rfe dans tous les ctres animes 
Bouchardat,— Du diabete sucre 

Annuaire de therapeutique, de matiere medicale, de 

pharmacie, et de toxicologic - 

Formulaire veterinaire 

Manuel de matSire mddicale, de Iherajicutique ct de 

pharmacie - ■ " ' 

Nouveau formulaire magistral - 

Bouchut. — Histoire de la medecine et des doctrines medicales 
— — Nonveaux elements de pathologic g^ncrale 

Traiti de Diagnostic ct de s^meiologie 

La vie et ses attributs. S" edition - . 

— — — — Traitepratiquedeamaladiesdesnouveau-nes. 7*edn. 
Bouchut et Desprea.^Dictiomiaire de medecine et de 

iherapeutique - - - - 

Atlas d'ophthalmoBcopie medicale, de cerebroscopie 

■ — De I'ftat nerveux aigu et chronique 

Bpugard.— Eludes sur le cancer 

Quillet.— Precis d'Hialoire de la Medicine 
BourgQOis.^Les passions dans leurs rapports avec la sanle 
les maladies I'aniour et le liberdnage - 



Baillierey Tindall^ and Cox's Standard French Works, 39 

Boumeville et P. Regnard. — Iconographie photo- 

graphique de la Salpetri^re - - - 

Tome III. Hyst^ro-^pilepsie. — Zones hystero- 

f^nes. — Sommeil. — Attaques de sommeil. — 
lypnotisme, somnambulisme, magnetisme,cata- 
lepsie, proced^s de magnetisation, avec 40 photo- 
graphies - - - - I 10 o 
Bra. — Etudes] sur le poids de Tencephale dans les maladies 
mentales- . . . . 
Brehm. — La vie des animaux illustree — Les mammifbres 

Ditto ditto Les oiseaux 

Ditto ditto Les insectes 

Ditto ditto Les poissons 

Briand et Chaude. — Manuel complet de medecine legale. 

io« Edition .... 

BurdeL — Du cancer considere comme souche tuberculeuse 
Cadet de Gassicourt. — Traits clinique des maladies de 

Tenfance - - - 2 vols. 

Cadiat. — ^Trait6 d'anatomie geri^rale appliquee ^ la medicine. 

Embryologie, Elements anatomiques, tissus et 

syst^mes - - - 2 vols, 

Cauvet. — Nouveaux dements d'histoire naturelle medicale - 
Cazeaux. — Traite de I'art des accouchements 
Cerise. — Melanges medico-psycologiques - - - 

Chantreuil. — Clinique d'accouchements. Le9ons faites a 

rh6pital des cliniques. Par le docteur Lorde- 

reau - - -. - 

Chapius. — Precis de Toxicologic - - . 

Charpentier. — Traits pratique des Accouchements 2 ^ols, 
Charcot. — Le9ons sur les maladies des vieillards et les maladies 

chroniques, par le docteur Ball. 2« edition 
— ^^— — Le9ons sur les maladies du systeme nerveux ; 

par le docteur Bourneville - - 2 vols, 

Le9ons sur les maladies du foie des voies biliaires 

et des reins, par les docteurs Boumeville et Se- 

vestre - - - - -0120 

Le9ons sur les localisations dans les maladies du cer- 

veau, et de la Moelle Epiniere, par les docteurs 
Boumeville et Bressaud - - -0120 

■— ^— (J.M.)* — Le9ons sur les conditions pathologiques de 

Talbuminurie. Recueillies par E. Brissaud - 030 

Charon. — Contribution k la pathologic de Tenfanc? 2e edn. 060 
Chatin. — Les organes des sens dans le s^rie animale • o T2 o 

ChaufiTard. — La vie, etudes et problemes de biologic gen^rale 076 
Chauveau. — Anatomic compart des animaux domestiques - 150 
Chauvel. — Precis d*operations de chirurgie - - c 6 o 

Chretien. — Nouveaux elements de medecine operatoire - 060 

Civiale. — La Lithotritie et la Taille - - - o 16 o 

Codex Medicamentarius, pharmacop^e fran9aise - -096 

Colin. — Traite de physiologic comparee des animaux 2 vols, 160 

(Leon). — De la Fi^vre Typhoide dans Tarmee - 080 

Coxnite-Consultatif d'hygi^ne publicjue de France, recueil 
des travaux et des actes ofhciels de ^administration 
sanitaire, chaque vol. - - -080 

Coxnte. — Stracture et physiologic de ITiomme, demontrees i 

raidedesfigurescolori^s,d^coupees, etsuperposees 046 
Corlieu. — Aide-memoire de medecine, de chirurgie, et d'ac- 
couchements - - - -060 






2 


6 


I 


2 





I 


2 





I 


2 





I 


2 





I 


4 








3 





I 


4 





I 


2 





I 


2 





I 


8 








12 








16 








7 


6 





3 








8 





I 


10 








8 





I 


10 






40 BaillHre, T^ndaJl, and Cox's Standard French Wgrks. 



Cornil et Ranvler, — Manuel d'histologie pathologique. 

L'ouvrage complet formcra, z vols. vol. I. 

vol 2, port I. 

Courty.— Traits pratique des maladies de I'uL^rus des ovaires 

CruveilhleretSee .— Trai le d'analomie descriptive (complet) ■ 

Vol. I. — Ostikilogic, Arthroli^e eC le Myologie 

— Vol. 2. — Splanchnologie et organes des Bens 

Vol. 3.— Angciolc^c et Ncvrologie 

Cruvellhier. — Traited'anatomiepathologiqueginerale ^vob. 

— Anatomie pathologique du corps hiimain. 41 liv- 

ns. chaque 



ologie. la palhologie, et la tfierapeutique 
Dagonel. — Nouveau trait6 de mnladici- mentales - 
Daremberg.^ — Hisloire des sciences mddicales - 2 lio/r. 

■ M^eeine, histoire et doctrines- 

Davalne. — Traill des entoioairea et des maladies vermineuaes 

de lli'imme et des animaux domes! iijues. 2i edn. 
Decaye. — Precis de Thdrapentique Chiiurgicale 
Demarquay. — De la regeneration des organes et des tissus - 
Cepaul. — LepJiis de clinique obstetricale, redigees par M. le 
doeleurDc Soyre - - - ivals. 

DeschampH. — Compendium de pharmacie pratique 
De Sinety. — Traitc Pratique de Gynecologie et des maladies 

des femmcs. 2t edition 
Desmarres. — Lemons cliniques sur la Chirureie oculaire 
Despine and PiCOt. — Manuel pratique des maladies de 

Dolbeau. — Lemons de clinique chinu-gicale 

De la lithotritie p^rin^ale 

Donne-— Hygiene dea gens dn monde 



Dor.— Echelle pour m 

planches ei 

Dorvault. — Officine 01 



I chromalique 
e gen^rale de pharmi 



Duchenne.— be t'eTeclrisation localis^e- 
Duchenne.- — I'hyiaologie des Mouvements 

■ Mecanisme de la pbysionomic humainc - 

Dujardln-BeaumetK. — Lejons de clinique thfrapeulique 

professees a I'hopital Saint Antoine 
Dupuy .^Manuel d'hyglene publique et industrielle ou manuel 
pratique des attributions des membres des con- 
sells d'hypine - - . . 
Durand-Fardel,—Traili pratique des maladies ehroniques 

Traitc pratique des malttdics des vieillards 

Traits clinique et th^peutique du diabitc 

Du Saulle,— Les Hysteriques, flat physiaue et ^tat mental - 
Duval et Le re boul let. —Manuel du microscope, a" edn. 
£ngel. — Nouveaux Kidmen ts de Chimie Medicare et de 
Chiniie Biologique ... 

Faiio.— Traits elcmenlairc de ehlmi^e - - a vols. 




Bailliire, TtridaH, and Cox's Standard French Works. 41 

Farabouf.^Pr&is de Manuel opcratoire - 

Fau. — Annlomie artistique, noir, 4s. : coloriSe 

Fauvel. — Traite pratique des miladies du larynx, precede d'ur 

Iraite coroplel de laryngoscopie 
Ferrand.^ Premiers secaurs aux empoissoiiDes ou noyes 

-— Aide Memoire de Phamiicie - 

Fleury.— Traill tWrapeutique et clinique dliydratlieraple 
FoUin et Duplay.— Traite ilsmentoire de pathologie eitetn 

Fonsaagrives. — Hygiene alimentaire des mnlodes, des coi 
valescents el des valetudioaires ou du r^me e 
visage comme moyen Iherapeutiftue 

HygiineetassainissementdesVilles 

Principes de Therapentique g^irale 2" Sdilion 

Traile d'Hygitne oavale 

Therapentique de la Phlhisie pdnn 

sur tes indications, z* edJLion 
Traite de therapeutique appliqu^ bosee su 

dicatioDS ... 

Lefons d'hygi^ne infantile - 

Fort. — Analomie descriptive et dissection, 3> edition. 

Pathologie el clinique chirurgicaies 

Fournier. — Legons cliniques sur la Syphilis ^ludicf 

lieremeiit chei la. femme. 2" edition - 

La Syphilis du cerveau 

Syphilis el mariage - 

DeVOnnnisme 

Fovi He.— Elude clinique de la folic, a 

d^lire des grandeurs 

Moyens de coinbattce I'ivrognerie 

Foster. —Clinique Mcdicale de Montpellier, ■ 
Galezowskl.— Traite des maladies des yeux. 

Traiie iconograpbique d'ophlhalmoseopie 

Echelles typographiques et chromaliques 

et Dagurael.- Diagnostic el Traitement des 

aflections Oculaires 
Gallard. — Lemons clinique sui les maladies des femmes 
Gallei.— Histoire des kysles de I'ovaire - 
Gamier. — Dictionnaire annuel des progrte des s 

institutions niA3icales 
Garrfgou. — Bncniresde Luchon 
Gaujot et Spillman.— La chirurgie ci 
Gayrard, — LaMelhodedesM ethodes clefdelalangue Fran9aise 
Gervals et Van Benenden.— Zoologie modicale 
Gintrac. — Cours th^orique et clinique de pathologie in 

de thdrapie miJiJicale - - gvols. 

Girard. — Les Insectes ; ItaitG £16mentaiie d'entotnoli^ie. 

Vol. I. Coleoptires. : Vol. II. Orthopter. 

Avec, atlas, coIori£ 

Ditto, ditto, noire - 

Giraud-Teulon.— La vision Bt ses anomalies 
Godron.^De I'esptce et des races dans les el 
GofTres. — Precis iconograpbique des bandages, pansements, e 

appareils. Figures iioires, iSs. Coluriees 
Gosselin.— Cliniquechirurgicaiedel'h6pitaldetaChariie. 3tii/r. 
Goubert. — Manuel de i'an des autopsies cadav^riqiies, surt 

dans ses application a I'analomie palliologique 
Graefe. — Clinique oph thai mologi que 



42 BaillUrt, Tindall, and Coiis Standard French Works. 



Grasaet. — Traite pratique des maladies du sjsleme nerveuj; 

Grehant.— Majiuel de phisiquc m^dicale 
Grimaux. — Chimiqne organique elemenlaire 

Chimique inorganiqae *lenienla;re 

Gubter.^Commentiutes IhSrapeutiques <Iu Codex m^dicamen- 

tarius. 2, edition .... 
Guibourt. — HistiOire neturelle des drogues ^mples ^vols. 
Guillemln. — Les bandages et les appareils \ ftacluies 
Guttniaii.—Trait^ du diagnoalic des maladies des orguies 

thoraciques et abdominaux - 
Guyon. — Elements de chirurgie clinique. a' edition 

— Lemons diniques sur lea maladies des voies urinaires 

Hacquart. — Botanique mWicale 

Heckel. — Histoire medicale et pharmaccutique des princi- 

£aux agents m^icamenteux - 
omil.— De la phthisie pulmonaire. zi^ition- 
HervieuJC. — Traile clinique el pratique des maladies puerpe- 

rales et des suites de couches 
Hetet et Pauller. — Traile ^l^mentnire de medecine l^alc - 
HlUairet. ^Trait* TheoriqueetpratiqiicdcstnolBdiesdela peau 
Hofmann. — Nouveaux dements de medicine legale 
Houel. — Manuel d'anatomie pathologique genCmle- 
Jaccoud. — Traile de pathologic interne, 1' Mition 

Lepjns de clinique medicale faites i, I'llflpital de la 

Lemons de clinique m61icale failesi I'h&pilal Lari- 

boisiire. 3" edition . , . 

Curabilite et Iraitement de la phthisic pulmonaire 

Jamain et Terrier.— Manuel de pathologie et de clinique 
chinirgicales ... ■^gl, \ 

Vol 3 sous presse vol. 2 

Manuel de petite chirurgie 

Jamain et Terrier.— Nouveautralt^^l^mentaired'aDatomie 
descriptive ct de preparations anatomiques. 

Avec figures colorizes 
Jeannel. — Prostitution dans les grnndes villes du 19' si^cle - 

Fonnnlaire niagialral et officinal international 

Kus3 et Duval. — CourB de physiologie. 5« Wition 
Laboulbene. — Anatomic Pathologique ... 
Lancereaux.— Trait£ d'anatotnic pathologique. Vol. I. Ana- 
tomic pathologique generale ... 
Vol. z Anatomic pathologique sfieciale. Anatomic 
pathologique des systimes. 1° Systime lymphatique. 
VoL 3 sous presse 

Lancereaux et Laclterbrauer, — Atlas d'anatomie palho- 
Iccique - - - . . 

Landolt. — Le diagnostic des maladies des yeux 
Latteux. — Manuel de technioue microscopique, t 
pratique pour ['elude et ' 



] Guide 



Laveran. — Nature parasitaii 

description d'un 

sang des malades atteints de ii^vTe pa lustre 

■ et Tesaier.— Nouveaux Aliments de Patholi^ic e 

de clinique Medicalcs. 2> Mition. 2 vols 
I^corche. — Traile du DiaWte- 
Maladies des Reins - 



7 6 
3 6 



SailiUrf, Tindall, and Cox's Standard French Works. 43 



Lecour,— Proslitution \ Paris eC i Londrcs. 1789 -il 
I^ ForL^ — La chinirgiE militairi; el les soci^les lie sc 

France el i I'elranger 
iJifoPt. — ^Traite de chimie hydtologique - 
Lego uesl.— Trait e de chirurgie de I'armee 
I.egraiid-du.SaullB,~Emdeinfdic(i-lfEa'esurrinterdiction 

desalienes et sur le conseil Judiciaiie - 

Les Hyst^riques. Elal physique elat mental 

Lerovoc— Elude sur le diabele sucre chez Ics enfanls 

Levy. — Traiie d'hygiSne pubtique et privfe 

LJebreich. — Atlas d'ophthalmoscopie repriaeatant I'^lat du 

fond de I'lcil visibles ^ ropbthalmoscDpe 
Littre et Robin. — Dictionnaire de medicine, de chirurgie, d 

pharmacie, de I'art v^t^rinaire. I4< Mitiou 
Llvon. — Manuel des Viviseclions 

I^Qget. — Traiie de physiolccie. 3eme edilion - 3 kd/i. 
Lorain.— Le cholera, observe ^ I'bdpital Salnl Anioinc 

L* pouls, ses variations dans les maladies - 

X.uton. — Etudes de therapeutique generale et speciale 
Luys. — Iconogiaphie pholt^raphique des centres nerveux 

Traili elinique et pratique des mnladies menlales 

Le Cetveau, sea fonciions 

Magnan.^De I'Alcoolisme, des diverees forme du delire 
Maui tot.— Auscultation ... 
Malgaigne.' — Manuel de medicine operatoire - ^ve- 
Traite d'anatomie chirurgicale et de chirurgie expfri- 

mentale ■ - - - z ' 

Mandl.— Hygitne de la Voix - 

— — Maladies du larynx el du pharynx 

Marais. — Guide pratique pour I'analyse des urines - 
Uarchand. — Des accidents qui peuvent compliquei ta re 

tiora des luxations traumatiques 
Marey.^Du mouvemeiil dans les fonciions dela vie 

Marvaud.— EiTets physiologiques et Ihcrapeutiques des ali- 



nents d eparene t 
i aliment!) d'epari 
tiques (caff, th^, el 



Mauaory et Salmon, — Manuel de I'art des accouchments 
Mayer. — Conseils aux femmes sur I'sge de tt 

Rapports conjugaux, sous le point devuede la popu- 

lation, sante et de la morale publique - 
Montmeja. — Pathologic iconographique du fond de I'oiil, 

traite d'ophthalmoscope 
Moquln Tandon. — Elements debotaniqucmedicale. 3«edn. 

Elements de zoologie medicale - 

Morache. — Ilygiine militaire - 

MoreL— Traite d'hislologie humaine. 3eme edn. - avet alias 

Naegele et Gemser.— Traite de Tart des accouchcmeiits ■ 

Natjuet.— Principes de chimi 

Nelaton. — Elements de pathologic chirurgicale - 5 vols. 

Vol. 6 sous presse 
NieUy.— Manuel d'obsletrique ou aide-memoire de I'elive et 

du practicien. 3,' ifdilion 
N ieme ye r.— Pathologic interne - - 2 i!ols. 

Nothnagel et Rossbach. — Nouveaux Elements de matiere 

medicale et de therapeutique expose de I'aclion 

physiolc^que el therapeutique des medicaments - 



44 Bailiiire, Tindall, and CoJi^i Standard -French IVorks. 









Nouvelle Navigation Astronomiiue Theorie et 

Pratique 
Oninius. — Guide pratique d'eleclrolheraqie. 2* edition 
Ore. — Etudes sar In transTusioD du sang - 
Pajot.— Truvaiui d'obstetriqne et de gynecoloeie - 
Paulet, — Resumi d'anatomie appliquee. 2c edition 
Paulier et Hetct.—Traile dcmeutaire de mCdidne legale, 

dejuiisptudence medicine etde toxicologic, iveli. 
Pean. — Legons de clinique chiruigitale ■ - 2 vols. 

Pelletan.— Le micruscope, son emploi et des applications ■ 
Penard — Guide piatiquede raccoucheui eide la sage-remnie 
Peter.— Lemons de clinique inedicale - -"' ■ 

Petrequln.^ — Nouvcnux melanges de chini^e et de medi 
Peuch et Toussaint. — Precis dechirutgievcterinaire.ai'o/j, 
Perron et Poncet.— Alias des Maladies profondes de i'Oeil, 
compreaant 1 'Ophthalmoscopic et I'AnaloEnie patho- 
logique, 92 planches en chiomo-lithographie 
Pidoux — Eludes sur la phlhisie 

La mWicine experimenlale scs fooclions, 

Plnard — Vices de conformation du liassin 
Contre indications dc la verson dons la pr 

de r^paule 
Planchon. — Traite pratique de k delermination des drogaes 

simples d'origine vegelale '" 

Poggiale. — Traite d'analyse clinique 
Potiicare.— LaphysiologienormaleduSyai^meNerveuii, 3iwi!f. 
Quatrefages et Mamy. — Les cranes des races humnin 
Quatrefagea. — Honiines Fossiles et Hommes .Sauvages 
Quetelet.^Anthromopetrie, ou mesure des differentes faculli 

de I'homme 
Racle. — Traii^ de diagnostic imSdical, guide clinique poui 

1 'etude des signes coraclijtistiques des maladies 
Ranvier.— Lcfons d'aaatotnie generaie 

Sur le SystimeMuBculaire 

Trail* Technique d'Histolt^e - 

Requin. — Elements du pathologic medicaie • 4 tx 

Revel He- Pa rise et Carriere. — Physiologic et hygiene < 

hommes . . - - 

Riant. — Lemons dTiygiene, adoplcpar le minislte de I'instr 

tion publique pour les lyc^ el les ecoles normale; 
Richard.— Hiitoire de la grfn^raiioo 
Riche.— ManueldeChimieMedicaleetPharmaceulique. 3<edn. 
Richer. — Eludes cliniques sur I'hyBlere ^pilepsie on grande 

hyslerie . - - - 

Richet, A.— Ttaiti pratique li'analomie mWicale-chirurgicali 

Structure des ccrconvolu lions cerebrales . 

Rllllet, Barthez et Sanne.— Maladies des Enfanls. 3 
Wilion. - - - - j/el. 1 

Rindfleisch.— Traild d'histologie pathologique 
Rizat.— Manuel pralioue des maladies veneriennes - 
Robin. — Programmedu couis d'histologie 

Evolulion de la nolocorde 

Traite du microscope. 

Anolomie et physiologic celhilaire 



BaiUHre, lYniiali, and Co^s Standard French Works. 45 

£ s. d. 
Robin et Beraud, — Elements de Physiolog[e dc I'homme, et 

de; prindpcLux vert^br^ - - 3 vols, o iz o 

RoaenthaJ.— L>^ ncrrs et les niuc!es ■ - .-060 

Ronbaud. — Trnile de rimpuissincc et de li stcrilite - -080 

SaboU.—Traitc dels science et de I'acl des accouchements - a 13 o 
Sandras et Bourg^uinon. —. Trait^ pratique des maJadies 

Saint Germaiii. — Chirurgie OrthopLedique Therapeutique - 090 
Saint-Marc, Meauz.— L'ccole de salerne traduction en vers 

Francis. Avec U ttxie latin • • -070 

Saint-Vincent. — Nouvelle medecine dea families - -036 

Sanne.^Traitedeladiphlherie- - - - o 10 o 

Sappey. — Les elements flgurea da sang dans U serie animale ; 
conslitntion, origine,evolation, alterations niorbidesde 
cea^el^QieDts ; 15 plancbea lithographl^es et coloriees 2 □ o 
— Traite d'anatomie descriptive - - 4 vo/i. 300 

English edition, same price 

Schimper.— Traite de paleontologie vegetale, ante alias 3 vols. 7100 
Sedillot et Legouest. — Traite deraedecineoperatoire. z vols. 100 
See. — Da Diagnostic et du traitement des maladies du ctear 

et en particalier de leur formes anotnales - - □ 11 o 

Senac.— Traitment des coliques h^patiques -050 

Simon. — Conferences therapeuliques et cliniques sur les mala- 
dies des en fan ts ■ ■ - -070 
Sonberan.— Nouveau dictionnaire des falsification el des altera- 
tions des aliments des medicaments, etc. - - o 14 o 
Sous. — Traill d'Oplique consideree dans ses rapports avec 

Tardieu.^Dictionnaired'llygienepubliqueetdesalubrit44i/u/j'. 112 o 

Etude Mbdico-Legale sur les blessures par im- 

prudence, I'homicide, et les coups involontaires - 060 

Ditto ditto sur la pendaisoQ, la strangulation, et la 

suffocation - - - -050 

Ditto ditto SL 







— ■ Ditto ditto sur les attentats aux m 








Ditto ditto sur k folic 




Ditto ditto sur I'identite 






dentellement 




ce, negligence 






Tillaox.— Traiti d'anatomie topographique. 


i' Edition 



Trousseau.— Clinique medicale de 1 Hotel-Die a de Paris 
Trousseaa et Pidouz, — Traits de therapeutique et de mati^re 

medicale - - - z vols. 

Valleix. — Guide dii m^decin [iracticien, resumf g^n^ral de 

pathologic et de therapeutique appliquees, 5 vols. 
Vander-Colmc. — Hisloire bolanique et therapeutique des 

salsepareilles . . . - 

Vanlair. ^Les n^vralgies leur formes et leur traitement 
Velpeau et Beraud.— Manuel d'analomie ehirurgicale generale 

et topographique . - - . 

Verneau. — Le Bassin dans les sexes et dans les races 
Verrier. — Guide du Medccin Practicien et de la Sage femme - 
Vidal.— Traite de pathologic exteme et de medicine opfiratoire 
Virchow. — Palholc^e des tumeurs -" - 3 vols. 



46 Bailliire, Tiniall, and Cox'i Standard Frtneh Works. 



Voiain.— Le;ons cliniqaes sui les malsdics mentnles profess^ 
i k Salp<|[riire . - - - 

-: Lemons diniquES sur les maladies menlales el anr les 

maladies nerveuses, avec pholographiea, planches 
lithogiaphies et figures duns le texle - 

Vulpiftn. — Lemons de physiologic genernle et compute du 
systime netveun - _ ■ 

Leijona surl'aciionphysiQlogiquectpathoIc^que des 

substances toxiquea e[ medicameateuses 

Lefons sur I'appareil vasso-raoteor - 2 voh. 

Wagner.— Trait^ de chiniie industrielle - - 2 veh. 

Waaseige.^Des opdralions obsl^iricales - 

Wecker et Landolt. ~ TraJl6 complet d'ophthalmologie. 
Aoalotnie microscopique - ■ ■vel. I 

Vol.2 Maladies de la cum^. sous prase 

Vol. 3 RefracLion et accommodation 

Weckeret Masaelon.— Ophlhalinoscopie clinique ■ 

'■ — TWrapeutique oculaire 

— — — Chirurgie oculaire . ■ . . 

Echelle m^trique pour mesurer I'scuil^ visuelle 

Wiet— Colli ribulions & 1 etude delongation dcs nerfs 
Witkowski.— Structure et Functions ilu Corps Humain 
Woillez. — Dictionnaire de diagnostic medical, compreaant le 

diagnostic raisonne de chaque maladie, leur signes, etc. 



Wunderlich, — De la temperature dans le maladies - 
Wimdt. — Traits ^l^metitaire de physique mfdicale, traduit de 
I'AlIemand par le Dr. Monoyer 

Noveaux elements de physiologic hnmaine 

Wurtz. — La Theorie alomiquc .... 



Valuable Scientific Dictionaries iw c 



FPUBLICATrON. 



Dictionnaire de Chimie pare et appliquee par Ad. 
Wurtz, en livraisons .... 

Dictionnaire de Medecine, de chirurgie, etdTiyEi^ne 
yhfxvDsxtfs. Edition entierements refoodue par A. Zundel, 
en 6 parlies .-..-. 

Dictionnaire Encyclopedique des Sciences Medi- 
cales publiif par demi-volume de ehacun 400 pages et en 
quartre series simultan^ : ta premiere, commenfant par la 
lettre A, la dcuxif^me par la lettre L, la tioisieme par la 
leltre Q, et la quatrieme par F - 

Dictionnaire de Thfirapeutique de Matiere Med- 
icate, de Fharmacologie, de Toxicologic et des Eaux 
Minerales par Dujardin-Eeaumelz. Public en 15 fascicules 

Dictionnaire de Medecine, de chirui^e, de Phartna. 

cie, de I'Art Velerinaiceet des Sciences qui s'yrapportent. 

15' edition par Litlre en 4 Taicicuies, chaque ■ 
Dictionnaire usuel des Sciences Medicates par les Doc- 

teurs Dechanibre, Mathios Duval et S. LerebouiUet. £n 6 

fascicules, chaque - ■ . . 

Nouveau Dictionnaire de Medecine et de chi- 
rurgie pratiques, d'eiiviton 36 volumes, chaque 



Bailliire, Tindall, and Cox's Standard Frmck JVorks. 47 



BIBLIOTHEQUE 



PHILOSOPHIE CONTEMPORAINE. 



In Volum: 
Alaux. — Philoaophie de M. Cousin. 



.6d. e. 



I 



.e dans k philos. fran;. 



Auber, Ed. — Philosophic de In medecine. 
Beaussire.— AnlecMents de I'Hegelianisme 
Bentham et Grote. — La religion naturdle. 
Bersot, Ernest. — Libre philosophic. 
Bertauld.— L'ordte social d I'ordre moral. 

Philosophie Sociale. 

Bost— Le Protestantisme liberal. 

Bouillier (Frandsque).— De la conscience en P.sychologie, 

Boutmy, E. — Philosophie de I'BrcIiitecIiire en Grece. 

Buchner, L.— Science et nature. 3 vols. [de Humboldt. 

Challemel Lacour. — La philosophie indiyidnalisle, ^tude sat Gullaume 

Coignet, C. — La morale independante, [lianisnie. 

Coquerel, Ath. — Des premises transformations historiques du chris- 

■ La conscience et la foi. 

Histoirc du credo. 

Dumont — Haeckel et la Theorie de I'Evolution en AUemagnc. 

Esmnas. — Philosophie Experi men tale en Italie. 

Fttlvre. — De la variability des esptees. 

Fontflnes.— Le chrislianisme moiieme. Etude sur Lessing. 

Fonvielle, W. de. — L'astronomie moderne. 

Franck, Ad. -—Philosophie du droit penal. 

Philosophie du droit eccl^iastique. 

La Philosophie mystique en Piance au xviii* siecle. 

Gamier, Ad. — Dela morale dans I'antiquili. 
Gaudtler.— Le Beau et son histoire. 

Haeckel. — Les preuves du trans formis me, 

Essais de PsycholoEie cellulaiie. 

HaTtmann.— -La Religion de I'Avenir. 

— -— La Darwinisme ce qu'il y a de vrai et de faux dans cette theorie. 
Herzon.—PhysioloEie de la Volonie. 
Janet, Paul. — Le mat^rialisme contemporain. 

La crise philosophique. MM. Taine, Kenan, Vacherot, Litlr^, 

- — - Philosophie de la revolution fran9aise. 



:e inedile de Spin< 



- Saint Simon et le St. Sim 

Dieu, I'Homme, et la Beatitude {CEuv 

Laugel, Aug^uate. — Les problemes de la n: 

Les prolilfnies de la vie. 

Les probl^tmes de Tame. 

La voii, rorellle, et la musique. 

L'optiqiie et les art. 

Laveleye, Em, de.— Les formes de gouvernement. 
Leblais.^Materialisme et spiritualism e, preface pat M. E, Lillre. 
Lemoine, Albert. — Le vitalisme et I'animisme de Stahl. 

De la pbysionomie el de la parole. 

L'habitudeet I'instinct Etudes de psychologie compar^e. 

Leopardi.— Opuscules et Pens^s. 

Levalloise, Jules. — Deisme et christianisme. 
Leveque, Charles.- — Le spiiitualisme dans I'art. 

La bcieiice de I'invisible. Elude de psychologie et de ihcodicci 



48 BaillUrt, Tin4al2, and Cex^s Standard Frauh Works. 

Lkrd. — Le Leadens Angiais. 

Lotse.^Ptincipes geo^raux de Psychologie Physiolt^quc, 

L'Utilitansme. 

MargaU.— Les Nationalites. 

Manano. — La philosophic contemporaine en Italic. 

Marion, —Locke, sa vie ei son teuvtc. 

Milt, Stuart. — ^Augoste Comte et la philosophic positire. 

Milsand.— L'eslh^tiqueanglaise, ^tade sur John Ruskin. 

Odysse-Barot. — Philosophic de I'histoire. 

Rcmusat, Charles de.^Philosophie leligieuse. 

Rerille, A. — Histoite du di^me dc la divinity de J^sus-Chrisl. 

Ribot. — Philosophic de Schopenhauer. 

La Maladies de la M^moice. 

Roiscl.— De 1b Substance. 
Saig'ey. — La physique modcine. 

Sai^et, Emile.—L'amc et la vie, une ^lude sai I'estheliquc fran^. 

Critique et histoire de la philosophie. 

Schmidt. —Les sciences naturelles et I'inconscient. 
Schixbel.— Philosophie dc la laison pure. 
Schopealiauer.^Essai sur le libre arbiire. 
— — Fondemenl de la Morale. 

Pens^es et Fragments, 

Selden, Camille.^La musique en AUemagne. Mendelssohn. 

Siciiiani. — Psychc^nie modernc. 

Spencer, Herbert, — Classification des sciences. 

Spinoza.— Dieu, ITiomme et la beatitude. 

St Hilaire.— De la Metapbysique. 

Taine, H.— Le positivisme anglais, etude sur Stuart Mill. 

L'id^alisme angiais, etude sur Carlylc. 

Philosophie de I'art en Ilalie. 

Philosophie de I'arl dans lea Pays-Bas. 

Philosophie de I'art en Grice. 

Vacherot, Et.— La science et la conscience. 
Vera, A.— Essais de philosophie H^g^lienne. 
Zeller, — ^Christian liaur et I'Ecole de Tubingue. 



Archives Generals de Medecitie. ist of each month. 

Le Progres Medical. Weekly. Post free, per annum, 2ij., in 

(Jreal Urilain and Ireland. 
Revtiedes Deux Mondes. ist and ijlh of every month, 3s, each. 
Revue Scientifique de la France et de I'Etrangei*. 

Weekly, (al. 
Revue Politique et Litteraire. Weekly, 6</. 
Revue Mensuelle de Medecine et de Chirurgie. 

Monthly, 21. ; 20J. per annum. 

Revue Philosophique de la France etdel'Etranger. 
Monthly, Ji. 



POSSIBLE NorrcE. 



Messrs. Bailliere, Tindali, 4 Cox. an the iptcially apfainlfd Agenh far 
Ihi Revue des Deux Mondes, and most of Ike Sdeitlijic and Medical 
J'eriffdkiUs of the Continciil.